Basic Information
| Provider Information | |||||||||
| NPI: | 1972055127 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMG - SOUTHERN TENNESSEE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHERN TENNESSEE PHYSIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 399 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373980399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319671333 | ||||||||
| FaxNumber: | 9319671888 | ||||||||
| Practice Location | |||||||||
| Address1: | 183 HOSPITAL RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | WINCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373982470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319622272 | ||||||||
| FaxNumber: | 9319628588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2016 | ||||||||
| LastUpdateDate: | 11/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | JUDY | ||||||||
| AuthorizedOfficialFirstName: | JESS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6159207214 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.