Healthcare Provider Details

I. General information

NPI: 1497954176
Provider Name (Legal Business Name): SYDNEY LOUIS COUSIN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 43RD ST RM 3H-1-053
RENTON WA
98055-5714
US

IV. Provider business mailing address

PO BOX 34876
SEATTLE WA
98124-1876
US

V. Phone/Fax

Practice location:
  • Phone: 425-228-3440
  • Fax:
Mailing address:
  • Phone: 425-656-5412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD60217641
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60217641
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: