NPIMap

Individual provider Active NPI

Derek Kelly Coburn, P.A.

  • Physician Assistant
  • Charlotte, NC
National Provider Identifier
1861851784
Registry record updated Jun 10, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
0010-06199 Issued in NC
Practice address
2001 Vail Ave
Charlotte, NC 28207-1248
Phone
(208) 863-8974
NPI assigned
Feb 19, 2016
Last updated
Jun 10, 2020By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 10, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 0010-06199 NC Primary
Emergency Medicine Physician 207P00000X 001006199 NC

Addresses

Primary practice location

2001 Vail Ave
Charlotte, NC 28207-1248

Mailing address

3740 Wendwood LN Apt 108
Charlotte, NC 28211-1257
Phone (208) 863-8974

Other practice location 1

14214 Ballantyne Lake Rd Ste 100
Charlotte, NC 28277-3373
Phone (704) 667-2650

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC, SC2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20160520001862 NC Practitioner - Physician Assistant 0840589438 Reassigns benefits to 5 organizations
I20201223001735 SC Practitioner - Physician Assistant 0840589438 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2015
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Carolinas Physicians Network IncGroup PAC ID 3375449655, shared by 56 NPIs, 2,324 clinicians

Practice addresses (Care Compare)

119 Market Place Ave
Suite D
Mooresville, NC 28117-9157
Phone (704) 801-9140

12905 Rosedale Hill Ave
Huntersville, NC 28078-3341
Phone (704) 801-1000

14214 Ballantyne Lake Rd
Charlotte, NC 28277-3373

1426 E Morehead St
Charlotte, NC 28204-2926
Phone (704) 446-6090

1656 Riverchase Blvd
Suite 1800
Rock Hill, SC 29732-0282
Phone (803) 909-1850

1802 E Main St
Lincolnton, NC 28092-3915
Phone (980) 212-2610

2041 S Blvd
Suite 100
Charlotte, NC 28203-5775
Phone (704) 304-0140

3320 Robinwood Rd
Suite 100
Gastonia, NC 28054-6689
Phone (980) 487-2930

5727 Prosperity Crossing Dr
Suite 1100
Charlotte, NC 28269-5604
Phone (704) 863-9930

6030 W Hwy 74
Indian Trail, NC 28079-3469

704 Gold Hill Rd
Fort Mill, SC 29715-8906
Phone (803) 835-0420

9332 S Tryon St
Charlotte, NC 28273-3108
Phone (704) 587-6700

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
94 of 100Reported as apm
Quality
81.63
Promoting interoperability
100
Improvement activities
40

Merit-based Incentive Payment System (MIPS)

Final score
94 of 100Reported as apm
Quality
81.63
Promoting interoperability
100
Improvement activities
40

Merit-based Incentive Payment System (MIPS)

Final score
94 of 100Reported as apm
Quality
81.63
Promoting interoperability
100
Improvement activities
40

Merit-based Incentive Payment System (MIPS)

Final score
75 of 100Reported as group

Merit-based Incentive Payment System (MIPS)

Final score
94 of 100Reported as apm
Quality
81.63
Promoting interoperability
100
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
001006199NCMDEmergency Medicine Physician
0010-06199NCMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Carolinas Physicians Network Inc CurrentSince Sep 17, 2020 Accepting new patients
Gastonia Physician Services, PLLC Emergency Medicine CurrentSince Mar 2, 2016 Accepting new patients
Gastonia Physician Services, PLLC Emergency Medicine CurrentSince Mar 2, 2016 Accepting new patients
Carolinas Physicians Network Inc CurrentSince Aug 10, 2020 Accepting new patients
Carolinas Physicians Network Inc CurrentSince Aug 10, 2020 Accepting new patients

Locations

1000 Blythe Blvd
Charlotte, NC 28203
Phone (704) 351-3791

10628 Park Rd
Charlotte, NC 28210
Phone (704) 543-2000

14214 Ballantyne Lake Rd
Ste 100
Charlotte, NC 28277
Phone (704) 667-2650

14214 Ballantyne Lake Rd
Ste 300
Charlotte, NC 28277
Phone (704) 446-5070

2001 Vail Ave
Charlotte, NC 28207
Phone (704) 304-5000

5717 Albemarle Rd
Charlotte, NC 28212
Phone (704) 563-2150

9332 S Tryon St
Charlotte, NC 28273
Phone (704) 587-6700

2525 Court Dr
Gastonia, NC 28054
Phone (704) 834-2662

704 Gold Hill Rd
Ste 1200
Fort Mill, SC 29715
Phone (704) 667-3380

Interoperability endpoints

  • Direct secure messaging: dcoburn499942@carolinashealthcaresystem.direct-ci.com
  • FHIR API: https://api.platform.athenahealth.com/14272/brand/70/csg/1/fhir/r4

Organizations & group practices 11

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1455840000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1591747200000",
    "number": "1861851784",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3740 WENDWOOD LN APT 108",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282111257",
            "telephone_number": "208-863-8974"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2001 VAIL AVE",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282071248",
            "telephone_number": "208-863-8974"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "14214 Ballantyne Lake Rd Ste 100",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282773373",
            "country_code": "US",
            "telephone_number": "704-667-2650",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "COBURN",
        "first_name": "DEREK",
        "middle_name": "KELLY",
        "name_prefix": "Mr.",
        "credential": "P.A.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-02-19",
        "last_updated": "2020-06-10",
        "certification_date": "2020-06-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-06199",
            "primary": true
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "NC",
            "license": "001006199",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Charlotte, NC

Sources for this page

Verify at the official NPI Registry.