Provider Demographics
NPI:1205583044
Name:COLEMAN MEDICAL GROUP APMC
Entity type:Organization
Organization Name:COLEMAN MEDICAL GROUP APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-798-4539
Mailing Address - Street 1:PO BOX 5237
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5237
Mailing Address - Country:US
Mailing Address - Phone:318-798-4539
Mailing Address - Fax:
Practice Address - Street 1:200 SILVER FOX CIR
Practice Address - Street 2:
Practice Address - City:HAUGHTON
Practice Address - State:LA
Practice Address - Zip Code:71037-7704
Practice Address - Country:US
Practice Address - Phone:318-213-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-02
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1453340Medicaid