Provider Demographics
NPI:1730247263
Name:COALSON, MICHAEL A (LPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:COALSON
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 CLAWSON ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4702
Mailing Address - Country:US
Mailing Address - Phone:161-846-2113
Mailing Address - Fax:161-846-2373
Practice Address - Street 1:400 N CALDWELL ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:IL
Practice Address - Zip Code:62088-1423
Practice Address - Country:US
Practice Address - Phone:618-635-4273
Practice Address - Fax:618-635-4272
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK34379Medicare ID - Type Unspecified