Healthcare Provider Details

I. General information

NPI: 1528336286
Provider Name (Legal Business Name): AMG CROCKETT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 S LOCUST AVE
LAWRENCEBURG TN
38464-4061
US

IV. Provider business mailing address

1605 S LOCUST AVE
LAWRENCEBURG TN
38464-4061
US

V. Phone/Fax

Practice location:
  • Phone: 931-766-7994
  • Fax: 931-766-7984
Mailing address:
  • Phone: 931-766-7994
  • Fax: 931-766-7984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICK MEKO
Title or Position: DIRECTOR
Credential:
Phone: 615-427-2239