Healthcare Provider Details

I. General information

NPI: 1578714440
Provider Name (Legal Business Name): ANDREW M COUGHLIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 DODGE ST SUITE 304
OMAHA NE
68114-4108
US

IV. Provider business mailing address

PO BOX 10190
VIRGINIA BEACH VA
23450-0190
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-5048
  • Fax: 402-354-2585
Mailing address:
  • Phone: 800-477-5240
  • Fax: 757-463-6572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number27214
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberBP10032053
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number27214
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: