Provider Demographics
NPI:1265456669
Name:COFFEE FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:COFFEE FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-384-2353
Mailing Address - Street 1:200 DOCTORS DR
Mailing Address - Street 2:SUITE 224
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2201
Mailing Address - Country:US
Mailing Address - Phone:912-384-2353
Mailing Address - Fax:
Practice Address - Street 1:200 DOCTORS DR
Practice Address - Street 2:SUITE 224
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2201
Practice Address - Country:US
Practice Address - Phone:912-384-2353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA53885207Q00000X
GA004691363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7873Medicare ID - Type UnspecifiedGROUP NUMBER FOR MEDICARE