Provider Demographics
NPI:1104995281
Name:COFFEE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:COFFEE MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-461-3439
Mailing Address - Street 1:1001 MCARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-2419
Mailing Address - Country:US
Mailing Address - Phone:931-461-3436
Mailing Address - Fax:931-461-2587
Practice Address - Street 1:1001 MCARTHUR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2419
Practice Address - Country:US
Practice Address - Phone:931-461-3436
Practice Address - Fax:931-461-2587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000017282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44U007Medicare Oscar/Certification