Organization
AMG-CROCKETT, LLC
Active
Organization
AMG-CROCKETT, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JONE KOFORD (DIVISION PRESIDENT)
(615) 372-8503
Entity
Organization
Contact information
Practice address
1605 S LOCUST AVE, SUITE 103, LAWRENCEBURG, TN 38464-4053
(931) 762-6571
(931) 766-3339
Mailing address
PO BOX E, LAWRENCEBURG, TN 38464-0136
(931) 766-3637
(931) 766-7071
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
—
—
208800000X
Urology Physician
D0042141
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01069597
AMERIGROUP
TN
Enumeration date
04/20/2007
Last updated
05/18/2009
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