Basic Information
| Provider Information | |||||||||
| NPI: | 1376784918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOUSOULIS | ||||||||
| FirstName: | GEORGIA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105466400 | ||||||||
| FaxNumber: | 4106307685 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105437536 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2009 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | C5-0000659 | DE | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 363A00000X | C0006463 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.