MEDICARE: DR. EMERTH LANCE COBURN 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	207R00000X	Internal Medicine Physician	198832	NY
2	207Q00000X	Family Medicine Physician	198832	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477544096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EMERTH LANCE COBURN MD

Provider Business Mailing Address
First Line	:	214-01 110TH AVENUE
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11429
Country	:	US
Telephone Number	:	718-276-4482
Fax Number	:	718-276-4783

Provider Business Practice Location Address
First Line	:	21401 110TH AVE
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11429-1906
Country	:	US
Telephone Number	:	929-615-6447
Fax Number	:	718-276-4783

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	03/05/2025

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