Healthcare Provider Details

I. General information

NPI: 1336294222
Provider Name (Legal Business Name): AMG-SOUTHERN TENNESSEE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 HOSPITAL RD SUITE E
WINCHESTER TN
37398-2494
US

IV. Provider business mailing address

155 HOSPITAL RD SUITE E
WINCHESTER TN
37398-2494
US

V. Phone/Fax

Practice location:
  • Phone: 931-962-0672
  • Fax: 931-967-7817
Mailing address:
  • Phone: 931-962-0672
  • Fax: 931-967-7817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: BILL GRACEY
Title or Position: COO
Credential:
Phone: 615-372-8500