Healthcare Provider Details

I. General information

NPI: 1720040728
Provider Name (Legal Business Name): MICHAEL C COBURN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 10/04/2025
Certification Date: 10/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 TOWER HILL RD
NORTH KINGSTOWN RI
02852-6639
US

IV. Provider business mailing address

1950 TOWER HILL RD
NORTH KINGSTOWN RI
02852-6639
US

V. Phone/Fax

Practice location:
  • Phone: 401-559-3954
  • Fax: 401-294-4116
Mailing address:
  • Phone: 401-559-3954
  • Fax: 401-294-4116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMD08308
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberMD08308
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: