1659467157 NPI number — MARY K COUSINS NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659467157 NPI number — MARY K COUSINS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUSINS
Provider First Name:
MARY
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1659467157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
443 NE 100 STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI SHORES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33138-2446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-762-7305
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1611 NW 12 AVENUE
Provider Second Line Business Practice Location Address:
EAST TOWER 6005
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33136-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-585-5905
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2006

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: 363LF0000X , with the licence number:  9172104 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: F3330731 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 304054200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010369000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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