Provider Demographics
NPI:1821073883
Name:COUGHLIN, ERIC C (PT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:C
Last Name:COUGHLIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE. 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:1315 NW 4TH STREET
Practice Address - Street 2:SUITE B TAI CENTRAL OREGON REDMOND
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1328
Practice Address - Country:US
Practice Address - Phone:541-923-7494
Practice Address - Fax:541-504-9153
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4706225100000X
VT0400003482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232085Medicaid
ORP01384716OtherRR MEDICARE PTAN
ORR156124Medicare PIN
OR386526Medicare ID - Type Unspecified