1982748224 NPI number — JIMMY R COUGHRAN A MEDICAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982748224 NPI number — JIMMY R COUGHRAN A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JIMMY R COUGHRAN A MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982748224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 730
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINNSBORO
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71295-0730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-435-8020
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 FAIR AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINNSBORO
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71295-2116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-435-8020
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COUGHRAN
Authorized Official First Name:
JIMMY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
318-435-8020

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  021579 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1449130 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: L92023 . This is a "VANTAGE PROVIDER NO" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 5287021 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 433374280A . This is a "BCBS OF LA PROVIDER NO" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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