Provider Demographics
NPI:1841541117
Name:AMG - SOUTHERN TENNESSEE, LLC
Entity type:Organization
Organization Name:AMG - SOUTHERN TENNESSEE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7780
Mailing Address - Street 1:10054 OLD TULLAHOMA RD
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-6122
Mailing Address - Country:US
Mailing Address - Phone:931-967-8641
Mailing Address - Fax:931-455-0892
Practice Address - Street 1:10054 OLD TULLAHOMA RD
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388
Practice Address - Country:US
Practice Address - Phone:931-967-8641
Practice Address - Fax:931-455-0892
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMG - SOUTHERN TENNESSEE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-27
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530024Medicaid
TN3716445Medicare PIN