Provider Demographics
NPI:1639211956
Name:COFFEE REGIONAL MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:COFFEE REGIONAL MEDICAL CENTER, INC
Other - Org Name:COFFEE REGIONAL FIRST CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
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:912-383-5667
Practice Address - Street 1:1301 PETERSON AVE S
Practice Address - Street 2:STE B
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2327
Practice Address - Country:US
Practice Address - Phone:912-383-6966
Practice Address - Fax:912-383-5667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000448DMedicaid
GA113460Medicare Oscar/Certification