Healthcare Provider Details

I. General information

NPI: 1700318540
Provider Name (Legal Business Name): COLLEEN KRISTIN COGHLAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 04/29/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. DEPT. OF ANESTHESIOLOGY
EVANSTON IL
60201-1057
US

IV. Provider business mailing address

2650 RIDGE AVE. DEPT. OF ANESTHESIOLOGY
EVANSTON IL
60201-1057
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2760
  • Fax:
Mailing address:
  • Phone: 847-570-2760
  • 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 Code207L00000X
TaxonomyAnesthesiology Physician
License Number125.071683
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036156059
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: