Provider Demographics
NPI:1356791636
Name:COUGHLIN, KIMBERLY ROSE (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ROSE
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22101 MOROSS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29000 LITTLE MACK AVE STE B
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3018
Practice Address - Country:US
Practice Address - Phone:586-774-8811
Practice Address - Fax:586-541-0199
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301109635390200000X
MI4301506652208600000X
NY309316208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program