Basic Information
Provider Information | |||||||||
NPI: | 1295722429 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COUP | ||||||||
FirstName: | GREGG | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7301 E FRONTAGE RD | ||||||||
Address2: |   | ||||||||
City: | MERRIAM | ||||||||
State: | KS | ||||||||
PostalCode: | 662041632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136762489 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7301 E FRONTAGE RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MERRIAM | ||||||||
State: | KS | ||||||||
PostalCode: | 662041632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9133844040 | ||||||||
FaxNumber: | 9133844093 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2005 | ||||||||
LastUpdateDate: | 02/21/2014 | ||||||||
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 | 207Q00000X | 30430 | KS | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 103684 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER | 473350 | 01 | KS | FIRST GUARD | OTHER | 0000103684 | 01 | KS | TRICARE | OTHER |