Basic Information
| Provider Information | |||||||||
| NPI: | 1215941646 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COFFEE COUNTY HOSPITAL GROUP, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MEDICAL CENTER OF MANCHESTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1409 | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373494409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317286354 | ||||||||
| FaxNumber: | 9317285420 | ||||||||
| Practice Location | |||||||||
| Address1: | 481 INTERSTATE DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373553108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317286354 | ||||||||
| FaxNumber: | 9317285420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 06/02/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COUCH | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9317286354 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 000000000019 | TN | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 0441308 | 05 | TN | MEDICAID | 1000063 | 01 | TN | TENNCARE PROVIDER NUMBER | OTHER |