Basic Information
Provider Information | |||||||||
NPI: | 1952780454 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMG CROCKETT LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHERN TENNESSEE PRIMARY CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1009 N LOCUST AVE | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEBURG | ||||||||
State: | TN | ||||||||
PostalCode: | 384642746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9317620531 | ||||||||
FaxNumber: | 9317620998 | ||||||||
Practice Location | |||||||||
Address1: | 1009 N LOCUST AVE | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEBURG | ||||||||
State: | TN | ||||||||
PostalCode: | 384642746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9317620531 | ||||||||
FaxNumber: | 9317620998 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2015 | ||||||||
LastUpdateDate: | 05/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILLIS | ||||||||
AuthorizedOfficialFirstName: | CASEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9317664574 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.