Healthcare Provider Details

I. General information

NPI: 1164654547
Provider Name (Legal Business Name): AMG-HILLSIDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 E COLLEGE ST SUITE 500
PULASKI TN
38478-4515
US

IV. Provider business mailing address

PO BOX 1186
PULASKI TN
38478-1186
US

V. Phone/Fax

Practice location:
  • Phone: 931-363-7531
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number45230
License Number StateTN

VIII. Authorized Official

Name: MICHAEL CLARK
Title or Position: DIVISION PRESIDENT
Credential:
Phone: 615-372-8500