MEDICARE: AMG CROCKETT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1659514776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMG CROCKETT LLC

Provider Business Mailing Address
First Line	:	106 S MILITARY AVE
Second Line	:
City	:	LORETTO
State	:	TN
Zip	:	38469-2101
Country	:	US
Telephone Number	:	931-853-4622
Fax Number	:	931-853-4621

Provider Business Practice Location Address
First Line	:	106 S MILITARY AVE
Second Line	:
City	:	LORETTO
State	:	TN
Zip	:	38469-2101
Country	:	US
Telephone Number	:	931-853-4622
Fax Number	:	931-853-4621

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MICHAEL B CLARK
Credential	:
Telephone Number	:	615-372-8500

Provider Enumeration Date	:	04/20/2009
Last Update Date	:	04/20/2009

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Directions to “AMG CROCKETT LLC ” Practice Location

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