Healthcare Provider Details

I. General information

NPI: 1730260019
Provider Name (Legal Business Name): RANDOLPH P COUSINS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 BLACKMON RD
COLUMBUS GA
31909-4478
US

IV. Provider business mailing address

7301 BLACKMON RD
COLUMBUS GA
31909-4478
US

V. Phone/Fax

Practice location:
  • Phone: 706-568-2700
  • Fax: 706-568-2705
Mailing address:
  • Phone: 706-568-2700
  • Fax: 706-568-2705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004428
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: