Provider Demographics
NPI:1912125600
Name:AMG-CROCKETT, LLC
Entity Type:Organization
Organization Name:AMG-CROCKETT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8503
Mailing Address - Street 1:PO BOX E
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-0136
Mailing Address - Country:US
Mailing Address - Phone:931-766-3637
Mailing Address - Fax:931-766-7071
Practice Address - Street 1:1605 S LOCUST AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-4053
Practice Address - Country:US
Practice Address - Phone:931-762-6571
Practice Address - Fax:931-766-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084N0400X
MDD0042141208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN01069597OtherAMERIGROUP
TN01069597OtherAMERIGROUP