Provider Demographics
NPI:1396022463
Name:MVAG, INC
Entity Type:Organization
Organization Name:MVAG, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:NATHAN
Authorized Official - Last Name:LAURENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-752-4999
Mailing Address - Street 1:7485 POPLAR PIKE
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-5934
Mailing Address - Country:US
Mailing Address - Phone:901-752-4999
Mailing Address - Fax:901-752-3761
Practice Address - Street 1:7485 POPLAR PIKE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-5934
Practice Address - Country:US
Practice Address - Phone:901-752-4999
Practice Address - Fax:901-752-3761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000025017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty