1215941646 NPI number — COFFEE COUNTY HOSPITAL GROUP, INC

Table of content: (NPI 1215941646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215941646 NPI number — COFFEE COUNTY HOSPITAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COFFEE COUNTY HOSPITAL GROUP, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDICAL CENTER OF MANCHESTER
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215941646
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1409
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37349-4409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-728-6354
Provider Business Mailing Address Fax Number:
931-728-5420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
481 INTERSTATE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37355-3108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-728-6354
Provider Business Practice Location Address Fax Number:
931-728-5420
Provider Enumeration Date:
07/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COUCH
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
931-728-6354

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  000000000019 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0441308 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1000063 . This is a "TENNCARE PROVIDER NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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