MEDICARE: DR. MICHAEL J COUGHLIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	G30774	CA
2	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician	M3906	ID
3	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician	G30774	CA

General Provider Information

NPI Number	:	1023010824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL J COUGHLIN MD

Provider Business Mailing Address
First Line	:	3340 E GOLDSTONE WAY
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-1026
Country	:	US
Telephone Number	:	208-367-3330
Fax Number	:	208-367-3331

Provider Business Practice Location Address
First Line	:	400 PARNASSUS AVE
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94143-2202
Country	:	US
Telephone Number	:	415-476-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	05/15/2018

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