Basic Information
| Provider Information | |||||||||
| NPI: | 1881013332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COUGHLIN | ||||||||
| FirstName: | ANNE MARIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 783311 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191783311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844500 | ||||||||
| FaxNumber: | 4848840699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1627 CHEW ST | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109694300 | ||||||||
| FaxNumber: | 6109694332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS018532 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 103314180 | 05 | PA | MEDICAID |