Basic Information
| Provider Information | |||||||||
| NPI: | 1043444714 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATHENS MEDICAL GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1660 LAFAYETTE RD | ||||||||
| Address2: | |||||||||
| City: | CRAWFORDSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479334601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653645360 | ||||||||
| FaxNumber: | 7653592233 | ||||||||
| Practice Location | |||||||||
| Address1: | 1660 LAFAYETTE RD | ||||||||
| Address2: | |||||||||
| City: | CRAWFORDSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479334601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653645360 | ||||||||
| FaxNumber: | 7653592233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2009 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | TERRANCE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7654236161 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.