Provider Demographics
NPI:1891103438
Name:AMG - SOUTHERN TENNESSEE, LLC
Entity Type:Organization
Organization Name:AMG - SOUTHERN TENNESSEE, LLC
Other - Org Name:SOUTHERN TENNESSEE NEPHROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-0399
Mailing Address - Country:US
Mailing Address - Phone:931-968-2525
Mailing Address - Fax:931-968-2527
Practice Address - Street 1:155 HOSPITAL RD
Practice Address - Street 2:SUITE H
Practice Address - City:WINCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37398-2494
Practice Address - Country:US
Practice Address - Phone:931-928-2525
Practice Address - Fax:931-968-2527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1524625Medicaid