Provider Demographics
NPI:1427244706
Name:COPPIN STATE UNIVERSITY
Entity type:Organization
Organization Name:COPPIN STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAVON
Authorized Official - Middle Name:T
Authorized Official - Last Name:LEGETTE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:410-951-4188
Mailing Address - Street 1:2601 W. NORTH AVENUE
Mailing Address - Street 2:SUITE 131
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216
Mailing Address - Country:US
Mailing Address - Phone:410-951-4188
Mailing Address - Fax:410-951-6158
Practice Address - Street 1:2500 W NORTH AVE
Practice Address - Street 2:SUITE 131
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-3633
Practice Address - Country:US
Practice Address - Phone:410-951-4188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
MD261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216200700Medicaid
MD216500700Medicaid
MD216500700Medicaid