MEDICARE: AMG-SOUTHERN TENNESSEE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1093926404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMG-SOUTHERN TENNESSEE LLC

Provider Business Mailing Address
First Line	:	83 MEMORIAL DR
Second Line	:
City	:	WINCHESTER
State	:	TN
Zip	:	37398-2401
Country	:	US
Telephone Number	:	931-967-3966
Fax Number	:	931-962-0373

Provider Business Practice Location Address
First Line	:	83 MEMORIAL DR
Second Line	:
City	:	WINCHESTER
State	:	TN
Zip	:	37398-2401
Country	:	US
Telephone Number	:	931-967-3966
Fax Number	:	931-962-0373

Authorized Official
Title or Position	:	COO
Name	:	WILLIAM GRACECY
Credential	:
Telephone Number	:	615-372-8500

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	04/20/2008

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