Provider Demographics
NPI:1568493419
Name:WILLIAM N COUGHLIN MD SC
Entity Type:Organization
Organization Name:WILLIAM N COUGHLIN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:COUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-726-9020
Mailing Address - Street 1:2524 FARRAGUT DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-8400
Mailing Address - Country:US
Mailing Address - Phone:217-726-9020
Mailing Address - Fax:217-726-8343
Practice Address - Street 1:2524 FARRAGUT DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-8400
Practice Address - Country:US
Practice Address - Phone:217-726-9020
Practice Address - Fax:217-726-8343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056269207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056269Medicaid
IL205835Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL036056269Medicaid