Healthcare Provider Details

I. General information

NPI: 1659877967
Provider Name (Legal Business Name): COLEMAN KIDD COSGROVE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 N DEAN RD STE 300
AUBURN AL
36830-4034
US

IV. Provider business mailing address

1805 STAPLES CT
AUBURN AL
36830-2195
US

V. Phone/Fax

Practice location:
  • Phone: 334-734-5007
  • Fax: 334-325-2306
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number304344
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO.2720
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: