Provider Demographics
NPI:1215941646
Name:COFFEE COUNTY HOSPITAL GROUP, INC
Entity type:Organization
Organization Name:COFFEE COUNTY HOSPITAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:931-728-6354
Mailing Address - Street 1:PO BOX 1409
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37349-4409
Mailing Address - Country:US
Mailing Address - Phone:931-728-6354
Mailing Address - Fax:931-728-5420
Practice Address - Street 1:481 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3108
Practice Address - Country:US
Practice Address - Phone:931-728-6354
Practice Address - Fax:931-728-5420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000000000019282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0441308Medicaid
TN1000063OtherTENNCARE PROVIDER NUMBER
TN0441308Medicaid