Provider Demographics
NPI:1982748224
Name:JIMMY R COUGHRAN A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JIMMY R COUGHRAN A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:COUGHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-435-8020
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-0730
Mailing Address - Country:US
Mailing Address - Phone:318-435-8020
Mailing Address - Fax:
Practice Address - Street 1:101 FAIR AVENUE
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-2116
Practice Address - Country:US
Practice Address - Phone:318-435-8020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449130Medicaid
LAL92023OtherVANTAGE PROVIDER NO
LA5287021OtherAETNA PROVIDER NUMBER
LA433374280AOtherBCBS OF LA PROVIDER NO
LA5287021OtherAETNA PROVIDER NUMBER
LA1449130Medicaid