Provider Demographics
NPI:1437164878
Name:COFFEE COUNTY PHYSICIAN GROUP PC
Entity type:Organization
Organization Name:COFFEE COUNTY PHYSICIAN GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-732-0560
Mailing Address - Street 1:PO BOX 830525 DEPT SF 125
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35283-0525
Mailing Address - Country:US
Mailing Address - Phone:601-368-3290
Mailing Address - Fax:601-936-4389
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3727643Medicaid
AL345103Medicaid