1447300520 NPI number — TODD B COUSINS DO

Table of content: TODD B COUSINS DO (NPI 1447300520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447300520 NPI number — TODD B COUSINS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUSINS
Provider First Name:
TODD
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447300520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N ACADEMY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17822-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-271-6144
Provider Business Mailing Address Fax Number:
570-271-6578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132 ABIGAIL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT MATILDA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16870-7153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-272-5011
Provider Business Practice Location Address Fax Number:
814-272-6531
Provider Enumeration Date:
01/11/2007

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: 207LP2900X , with the licence number:  OS006836L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0014X , with the licence number: OS006836L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 01170201 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".