Organization Name: | AMG-SOUTHERN TENNESSEE LLC |
NPI Number: | 1073612578 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | WILLIAM GRACEY (COO) |
Mailing Address: | 10054 Old Tullahoma Rd Tullahoma |
State: | TN US |
Postal Code: | 373886122 |
Phone Number: | 9314556688 |
Fax Number: | 9314550892 |
NPI Enumeration Date: | 09/21/2006 |
NPI Last Update Date: | 06/17/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |