Healthcare Provider Details

I. General information

NPI: 1689968109
Provider Name (Legal Business Name): AMG-HILLSIDE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 01/30/2015
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 635
PULASKI TN
38478-0635
US

V. Phone/Fax

Practice location:
  • Phone: 931-363-8055
  • Fax: 931-363-8056
Mailing address:
  • Phone: 931-363-9308
  • Fax: 931-363-9430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JESS JUDY
Title or Position: PRESIDENT
Credential:
Phone: 615-372-8500