Healthcare Provider Details

I. General information

NPI: 1376784918
Provider Name (Legal Business Name): GEORGIA MARIA KOUSOULIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-7536
  • Fax:
Mailing address:
  • Phone: 410-546-6400
  • Fax: 410-630-7685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006463
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberC5-0000659
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: