Provider Demographics
NPI:1720040728
Name:COBURN, MICHAEL C (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:COBURN
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 1:1950 TOWER HILL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-6639
Mailing Address - Country:US
Mailing Address - Phone:401-559-3954
Mailing Address - Fax:401-294-4116
Practice Address - Street 1:1950 TOWER HILL RD
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-6639
Practice Address - Country:US
Practice Address - Phone:401-559-3954
Practice Address - Fax:401-294-4116
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD083082084A0401X
RI8308208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI005185OtherBCBSRI/CHIP
RI838-7OtherBCBSRI
RI7004684Medicaid
RI823373996OtherTIN
RI7004684Medicaid