Healthcare Provider Details

I. General information

NPI: 1477855112
Provider Name (Legal Business Name): AMG SOUTHERN TN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2578 MAIN ST
PALMER TN
37365-2730
US

IV. Provider business mailing address

2578 MAIN ST
PALMER TN
37365-2730
US

V. Phone/Fax

Practice location:
  • Phone: 931-779-3691
  • Fax: 931-779-3690
Mailing address:
  • Phone: 931-779-3691
  • Fax: 931-779-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICK MEKO
Title or Position: ADMIN
Credential:
Phone: 931-779-3691