Provider Demographics
NPI:1437120946
Name:COFFEE REGIONAL MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:COFFEE REGIONAL MEDICAL CENTER, INC
Other - Org Name:COFFEE REGIONAL MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-384-1900
Mailing Address - Street 1:PO BOX 1287
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-1287
Mailing Address - Country:US
Mailing Address - Phone:912-384-1900
Mailing Address - Fax:912-389-2105
Practice Address - Street 1:1101 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2207
Practice Address - Country:US
Practice Address - Phone:912-384-1900
Practice Address - Fax:912-389-2105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207L00000X, 367500000X
207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAHOSP178Medicare ID - Type UnspecifiedGROUP MEDICARE