Basic Information
| Provider Information | |||||||||
| NPI: | 1154423200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COBERLY | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRESSMAN | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 843966 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641843966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738843300 | ||||||||
| FaxNumber: | 5738840943 | ||||||||
| Practice Location | |||||||||
| Address1: | 4050 LINDELL BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631083297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143969363 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2006010965 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207ZP0102X | 2006010965 | MO | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZB0001X | 2006010965 | MO | Y | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204022305 | 05 | MO | MEDICAID | 211431 | 01 | MO | BLUE SHIELD | OTHER | 758219 | 01 | MO | HEALTHLINK | OTHER |