Basic Information
| Provider Information | |||||||||
| NPI: | 1174516330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COAN | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742616 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303742616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702198420 | ||||||||
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| Practice Location | |||||||||
| Address1: | 58 BIG A ROAD | ||||||||
| Address2: | |||||||||
| City: | TOCCOA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305776017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068866819 | ||||||||
| FaxNumber: | 7062825368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 33295 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000001834A | 05 | GA | MEDICAID | 000433947A | 05 | GA | MEDICAID |