=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689016412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES W COFFEY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2013
-----------------------------------------------------
Last Update Date | 02/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1055 N CURTIS RD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-367-6995
-----------------------------------------------------
Fax | 208-367-6953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3340 E GOLDSTONE WAY
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-367-6995
-----------------------------------------------------
Fax | 208-367-6953
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 9408267
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | M-14360
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 04-37537
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------