Provider Demographics
NPI:1063235331
Name:COUCH, MAX ROBERT (RN)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:ROBERT
Last Name:COUCH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 BRIDGEPORT WAY APT 212
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1961
Mailing Address - Country:US
Mailing Address - Phone:217-371-0066
Mailing Address - Fax:
Practice Address - Street 1:1500 BRIDGEPORT WAY
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-1956
Practice Address - Country:US
Practice Address - Phone:217-371-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041567463163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse