Provider Demographics
NPI:1629012604
Name:MCGRATH, COE MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:COE
Middle Name:MICHAEL
Last Name:MCGRATH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 CENTRAL PIKE
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3494
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:
Practice Address - Street 1:485 N CHANCERY ST STE B
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-2005
Practice Address - Country:US
Practice Address - Phone:931-304-8585
Practice Address - Fax:706-258-4715
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003567363AM0700X, 363A00000X
TN5080363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA980233632AMedicaid
TNT251117019Medicaid