Healthcare Provider Details

I. General information

NPI: 1992966097
Provider Name (Legal Business Name): AMG-SOUTHERN TENNESSEE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 SOUTH INDUSTRIAL PARK ROAD
COALMONT TN
37313
US

IV. Provider business mailing address

PO BOX 68
COALMONT TN
37313-0068
US

V. Phone/Fax

Practice location:
  • Phone: 931-692-0010
  • Fax: 931-692-0012
Mailing address:
  • Phone: 931-692-0010
  • Fax: 931-692-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM GRACEY
Title or Position: COO
Credential:
Phone: 615-372-8500