Basic Information
| Provider Information | |||||||||
| NPI: | 1124048145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COFFEY | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | N. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6896 W SNOWVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BRECKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441413214 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1215 E MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173370957 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 12/26/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 4301074886 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 4301074886 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0B51090 | 01 | MI | BLUE SHIELD | OTHER | 0102512592 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 200000001792 | 01 | MI | PHP | OTHER | 4866416 | 05 | MI | MEDICAID | 4723816 | 05 | MI | MEDICAID |