Provider Demographics
NPI:1891883765
Name:COYLE, KEVIN DON (MB BCH BAO LRCPSI)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DON
Last Name:COYLE
Suffix:
Gender:M
Credentials:MB BCH BAO LRCPSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5191 FIRST COAST TECH PKWY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0609
Mailing Address - Country:US
Mailing Address - Phone:904-223-3321
Mailing Address - Fax:
Practice Address - Street 1:3408 TROUT ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520
Practice Address - Country:US
Practice Address - Phone:912-466-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL24087207LP2900X
GA060819207LP2900X, 208VP0014X
NC2007-01110208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6400190003Medicare NSC
GA76385UMedicare UPIN
GA6400190001Medicare NSC
GA6400190002Medicare NSC