1962486712 NPI number — RANDALL JON COUSINS MD

Table of content: RANDALL JON COUSINS MD (NPI 1962486712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962486712 NPI number — RANDALL JON COUSINS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUSINS
Provider First Name:
RANDALL
Provider Middle Name:
JON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COUSINS
Provider Other First Name:
RANDY
Provider Other Middle Name:
JON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1962486712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 PLYMOUTH RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MINNETONKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55305-2366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-581-5250
Provider Business Mailing Address Fax Number:
763-581-5257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 PLYMOUTH RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55305-2366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-581-5250
Provider Business Practice Location Address Fax Number:
763-581-5257
Provider Enumeration Date:
12/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  27678 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 631570400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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