Healthcare Provider Details

I. General information

NPI: 1316480213
Provider Name (Legal Business Name): AMG - SOUTHERN TENNESSEE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2016
Last Update Date: 11/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HUNTERS LN SUITE 100
TULLAHOMA TN
37388-8263
US

IV. Provider business mailing address

PO BOX 399
WINCHESTER TN
37398-0399
US

V. Phone/Fax

Practice location:
  • Phone: 931-455-4616
  • Fax: 931-455-2362
Mailing address:
  • Phone: 931-455-4616
  • Fax: 931-455-2362

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 Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESS N. JUDY
Title or Position: PRESIDENT
Credential:
Phone: 615-920-7214