NPIMap

Organization Active NPI

Coffee Regional Medical Center, Inc

Doing business as Coffee Regional Medical Center

  • General Acute Care Hospital
  • Douglas, GA
National Provider Identifier
1760419527
Registry record updated Dec 17, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
License
034490 Issued in GA
Legal business name
COFFEE REGIONAL MEDICAL CENTER, INC
Doing business as
Coffee Regional Medical Center
Practice address
1101 Ocilla Road
Douglas, GA 31533-2207
Phone
(912) 384-1900
Fax
(912) 389-2112
NPI assigned
Jun 27, 2006
Last updated
Dec 17, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 17, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Vicki Lewis
Title
President/Ceo
Phone
(912) 384-1900

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Acute Care Hospital 282N00000X 034490 GA Primary

Addresses

Primary practice location

1101 Ocilla Road
Douglas, GA 31533-2207

Mailing address

P O Box 1227
Douglas, GA 31534-1227
Phone (912) 384-1900

Other identifiers 1

IdentifierTypeStateIssuer
00000448AMedicaidGA

Other names 1

  • Coffee Regional Medical Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040402000287 GA Part B Supplier - Clinic/Group Practice 4587656012 Receives reassigned benefits from 75 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Douglas, GA
O20100826000963 GA Part A Provider - Hospital 4587656012 Practice locations: Douglas, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1760419527. Details of each certification follow.

Hospital certification: CCN 110089

Legal name
COFFEE REGIONAL MEDICAL CENTER INC
Doing business as
COFFEE REGIONAL MEDICAL CENTER
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Mar 18, 1993
Beds
88
Ownership / control type
Hospital district or authority
Most recent change of ownership
Jan 1, 1995 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1995 in GA
Enrollment address
1101 Ocilla Rd
Douglas, GA 31533-2207
Other Hospital Practice Location
Hospital subgroups
Acute care

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Hospital

Medicare Care Compare
Listed as
Coffee Regional Medical Center, IncCCN 110089 · All quality measures
Overall star rating
3 of 5
Type
Acute Care Hospitals
Ownership
Government - Hospital District or Authority
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Locations

2010 Ocilla Rd
Douglas, GA 31533
Phone (912) 384-1477

205 Shirley Ave
Douglas, GA 31533
Phone (912) 260-5400

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Vicki Lewis Individual Corporate OfficerCeo/President May 12, 2014 100%
Lavonda Cravey Individual Corporate Officer Jul 24, 2015
W-2 Managing EmployeeController Jul 24, 2015
Operational/Managerial ControlController Jul 24, 2015

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Coffee Regional First CareDouglas, GA, CCN 113460 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Oct 1, 1996

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 55

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 55

Affiliated clinicians 125

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 125

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151366400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1418774400000",
    "number": "1760419527",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P O BOX 1227",
            "city": "DOUGLAS",
            "state": "GA",
            "postal_code": "315341227",
            "telephone_number": "912-384-1900",
            "fax_number": "912-389-2112"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1101 OCILLA ROAD",
            "city": "DOUGLAS",
            "state": "GA",
            "postal_code": "315332207",
            "telephone_number": "912-384-1900",
            "fax_number": "912-389-2112"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COFFEE REGIONAL MEDICAL CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-27",
        "last_updated": "2014-12-17",
        "status": "A",
        "authorized_official_last_name": "LEWIS",
        "authorized_official_first_name": "VICKI",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "912-384-1900",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "GA",
            "license": "034490",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00000448A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Coffee Regional Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Douglas, GA

Sources for this page

Verify at the official NPI Registry.