Basic Information
Provider Information | |||||||||
NPI: | 1043278450 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COULON | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 MEDICAL CENTER DR | ||||||||
Address2: | SUITE G-500 | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257013656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036911787 | ||||||||
FaxNumber: | 3046918711 | ||||||||
Practice Location | |||||||||
Address1: | 1600 MEDICAL CENTER DR. | ||||||||
Address2: | SUITE G-500 | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257013656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046911787 | ||||||||
FaxNumber: | 3046918711 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 04/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | MD.010050 | LA | N |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   | 207T00000X | 23103 | WV | Y |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 2837130 | 05 | OH |   | MEDICAID | 1142166 | 05 | LA |   | MEDICAID | 3810011593 | 05 | WV |   | MEDICAID | 7100046240 | 05 | KY |   | MEDICAID |