1639320732 NPI number — AMG-HILLSIDE LLC

Table of content: (NPI 1639320732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639320732 NPI number — AMG-HILLSIDE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMG-HILLSIDE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FOCUSED WOMENS HEALTHCARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639320732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1178
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PULASKI
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38478-1178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-207-8668
Provider Business Mailing Address Fax Number:
931-207-8671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 E COLLEGE ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PULASKI
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38478-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-207-8668
Provider Business Practice Location Address Fax Number:
931-363-3939
Provider Enumeration Date:
10/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
DIVISION PRESIDENT
Authorized Official Telephone Number:
615-372-8500

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1511382 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: CK2947 . This is a "RR GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4153524 . This is a "BCBS GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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