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General NPI Number Information
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NPI Number | 1265456669
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Entity Type | Organization
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Legal Business Name | COFFEE FAMILY MEDICINE, PC
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Dates
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Enumeration Date | 07/27/2006
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Last Update Date | 01/19/2012
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Provider Practice Location Address
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Address Line | 200 DOCTORS DR SUITE 224
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City | DOUGLAS
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State | GA
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Zip | 31533-2201
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Country | US
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Telephone | 912-384-2353
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Fax |
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Provider Business Mailing Address
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Address Line | 200 DOCTORS DR SUITE 224
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City | DOUGLAS
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State | GA
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Zip | 31533-2201
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Country | US
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Telephone | 912-384-2353
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. LYDIA TANNER
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Credential | M.D.
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Telephone | 912-384-2353
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 004691
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 53885
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License Number State | GA
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