Healthcare Provider Details

I. General information

NPI: 1265456669
Provider Name (Legal Business Name): COFFEE FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DOCTORS DR SUITE 224
DOUGLAS GA
31533-2201
US

IV. Provider business mailing address

200 DOCTORS DR SUITE 224
DOUGLAS GA
31533-2201
US

V. Phone/Fax

Practice location:
  • Phone: 912-384-2353
  • Fax:
Mailing address:
  • Phone: 912-384-2353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53885
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004691
License Number StateGA

VIII. Authorized Official

Name: DR. LYDIA TANNER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 912-384-2353