Provider Demographics
NPI:1558313197
Name:AMG- LIVINGSTON LLC
Entity Type:Organization
Organization Name:AMG- LIVINGSTON LLC
Other - Org Name:OVERTON FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WILLLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:529 MEDICAL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LIVINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:38570-1826
Mailing Address - Country:US
Mailing Address - Phone:931-823-1266
Mailing Address - Fax:931-823-7805
Practice Address - Street 1:529 MEDICAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:LIVINGSTON
Practice Address - State:TN
Practice Address - Zip Code:38570-1826
Practice Address - Country:US
Practice Address - Phone:931-823-1266
Practice Address - Fax:931-823-7805
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMG-LIVINGSTON LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3716474Medicaid
TN3716474Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER