Basic Information
| Provider Information | |||||||||
| NPI: | 1114180619 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SMG LAB PLLC IDTF | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 STEAM PLANT RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GALLATIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370663032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152308070 | ||||||||
| FaxNumber: | 6154521774 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 E BLEDSOE ST | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | GALLATIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370663054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154522511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | ALTON | ||||||||
| AuthorizedOfficialMiddleName: | SID | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6152308070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMNER MEDICAL GROUP PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 0000000544 | TN | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.