Healthcare Provider Details

I. General information

NPI: 1336441419
Provider Name (Legal Business Name): SHANE W. COUGHLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 UNION AVE SUITE 200
MEMPHIS TN
38104-3600
US

IV. Provider business mailing address

1407 UNION AVE SUITE 640
MEMPHIS TN
38104-3666
US

V. Phone/Fax

Practice location:
  • Phone: 901-866-8813
  • Fax: 901-302-2120
Mailing address:
  • Phone: 901-866-8360
  • Fax: 901-302-2360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMT213433
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: