MEDICARE: MICHELLE COBURN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management

General Provider Information

NPI Number	:	1164034633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE COBURN

Provider Business Mailing Address
First Line	:	8327 S LOOMIS BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-3958
Country	:	US
Telephone Number	:	708-573-6342
Fax Number	:

Provider Business Practice Location Address
First Line	:	8327 S LOOMIS BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-3958
Country	:	US
Telephone Number	:	708-573-6342
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2020
Last Update Date	:	08/17/2020

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Directions to “ MICHELLE COBURN ” Practice Location

Language	Start Address	Practice Location

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