Basic Information
| Provider Information | |||||||||
| NPI: | 1376646430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COFFMAN | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SOUTHER | ||||||||
| OtherFirstName: | SUZANNE | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | RR 4 BOX 286 | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042655643 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1322 LOCUST AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043678740 | ||||||||
| FaxNumber: | 3043669529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 09/10/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 133 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 001718501 | 01 | WV | BLUE CROSS BLUE SHIELD | OTHER | 55041919103 | 01 | WV | BRICKSTREET | OTHER | 0156077001 | 05 | WV | MEDICAID |