Basic Information
| Provider Information | |||||||||
| NPI: | 1912125600 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMG-CROCKETT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX E | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384640136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317663637 | ||||||||
| FaxNumber: | 9317667071 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 S LOCUST AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384644053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317626571 | ||||||||
| FaxNumber: | 9317663339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 05/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | KOFORD | ||||||||
| AuthorizedOfficialFirstName: | JONE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIVISION PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153728503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | D0042141 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 01069597 | 01 | TN | AMERIGROUP | OTHER |