Basic Information
| Provider Information | |||||||||
| NPI: | 1447300520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COUSINS | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
| FaxNumber: | 5702716578 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 ABIGAIL LN | ||||||||
| Address2: | |||||||||
| City: | PORT MATILDA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168707153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142725011 | ||||||||
| FaxNumber: | 8142726531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | OS006836L | PA | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207LP2900X | OS006836L | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01170201 | 05 | PA | MEDICAID |