Healthcare Provider Details

I. General information

NPI: 1740527753
Provider Name (Legal Business Name): AMG-HILLSIDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HILLSIDE DR
PULASKI TN
38478-4566
US

IV. Provider business mailing address

200 HILLSIDE DR
PULASKI TN
38478-4566
US

V. Phone/Fax

Practice location:
  • Phone: 931-424-9388
  • Fax: 931-424-9139
Mailing address:
  • Phone: 931-424-9388
  • Fax: 931-424-9139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JESS N JUDY
Title or Position: PRESIDENT
Credential:
Phone: 615-565-1508