Healthcare Provider Details

I. General information

NPI: 1720004880
Provider Name (Legal Business Name): ANTHONY JAMES COUSINEAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 S WEBSTER AVE
GREEN BAY WI
54301-2253
US

IV. Provider business mailing address

PO BOX 19070 PREVEA HEALTH
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax: 920-436-1319
Mailing address:
  • Phone: 920-496-4700
  • Fax: 920-436-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number34459
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: