Provider Demographics
NPI:1649209180
Name:COGHLAN, MICHAEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:COGHLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14TH MEDICAL GROUP 201 INDEPENDENCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39710-0001
Mailing Address - Country:US
Mailing Address - Phone:662-434-2273
Mailing Address - Fax:
Practice Address - Street 1:COLUMBUS AFB 14TH MEDICAL GROUP 201 INDEPENDENCE DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39710-0001
Practice Address - Country:US
Practice Address - Phone:662-434-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17128171000000X, 207RI0200X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL111729Medicaid
ALH40586Medicare UPIN
AL102I440451Medicare PIN