Healthcare Provider Details

I. General information

NPI: 1912125600
Provider Name (Legal Business Name): AMG-CROCKETT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 S LOCUST AVE SUITE 103
LAWRENCEBURG TN
38464-4053
US

IV. Provider business mailing address

PO BOX E
LAWRENCEBURG TN
38464-0136
US

V. Phone/Fax

Practice location:
  • Phone: 931-762-6571
  • Fax: 931-766-3339
Mailing address:
  • Phone: 931-766-3637
  • Fax: 931-766-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberD0042141
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: JONE KOFORD
Title or Position: DIVISION PRESIDENT
Credential:
Phone: 615-372-8503