Provider Demographics
NPI:1942489521
Name:AMERICAN MEDICAL GROUP PA
Entity Type:Organization
Organization Name:AMERICAN MEDICAL GROUP PA
Other - Org Name:CAREFIRST FAMILY AND INDUSTRIAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:903-455-8000
Mailing Address - Street 1:P.O. BOX 911
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75403-0911
Mailing Address - Country:US
Mailing Address - Phone:903-455-8000
Mailing Address - Fax:903-454-3577
Practice Address - Street 1:3800 JOE RAMSEY BLVD
Practice Address - Street 2:STE A
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-6486
Practice Address - Country:US
Practice Address - Phone:903-455-8000
Practice Address - Fax:903-454-3577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA67745Medicare UPIN
TX00U86MMedicare PIN