Provider Demographics
NPI:1508922303
Name:MICHAEL J COUGHLIN, MD, PA
Entity Type:Organization
Organization Name:MICHAEL J COUGHLIN, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:COUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-377-1000
Mailing Address - Street 1:901 N CURTIS RD
Mailing Address - Street 2:SUITE 503
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1338
Mailing Address - Country:US
Mailing Address - Phone:208-377-1000
Mailing Address - Fax:208-377-1003
Practice Address - Street 1:901 N CURTIS RD
Practice Address - Street 2:SUITE 503
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1338
Practice Address - Country:US
Practice Address - Phone:208-377-1000
Practice Address - Fax:208-377-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3906207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1376637Medicare ID - Type Unspecified