Healthcare Provider Details

I. General information

NPI: 1629430491
Provider Name (Legal Business Name): JULIA MARJORY COUGHLIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 W HARRISON ST
CHICAGO IL
60612-3825
US

IV. Provider business mailing address

1750 W HARRISON ST
CHICAGO IL
60612-3825
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6510
  • Fax: 312-942-2867
Mailing address:
  • Phone: 312-942-6510
  • Fax: 312-942-2867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036-171296
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: