Provider Demographics
NPI:1841292778
Name:COULSON, STEPHEN ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ANDREW
Last Name:COULSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 MARGATE LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2441
Mailing Address - Country:US
Mailing Address - Phone:847-910-2850
Mailing Address - Fax:
Practice Address - Street 1:1115 MARGATE LN
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2441
Practice Address - Country:US
Practice Address - Phone:847-910-2850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098320207P00000X, 207R00000X, 207RA0401X, 207RC0200X
IN01091281A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360983202Medicaid
ILH75884Medicare UPIN