MEDICARE: NANCY S KOUGHAN D.O.

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	2083P0901X	Public Health & General Preventive Medicine Physician	048532	GA

General Provider Information

NPI Number	:	1770588691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY S KOUGHAN D.O.

Provider Business Mailing Address
First Line	:	211 WILLOW LN
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-1430
Country	:	US
Telephone Number	:	404-508-7781
Fax Number	:	404-294-3272

Provider Business Practice Location Address
First Line	:	445 WINN WAY
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-1707
Country	:	US
Telephone Number	:	404-508-7881
Fax Number	:	404-294-3272

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/08/2007

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