Basic Information
| Provider Information | |||||||||
| NPI: | 1558340067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOUSSA | ||||||||
| FirstName: | SAMIR | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 551420 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333551420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 8558514405 | ||||||||
| Practice Location | |||||||||
| Address1: | 4725 N. FEDERAL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333084603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547718000 | ||||||||
| FaxNumber: | 9547763270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME 74360 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 254031200 | 05 | FL | MEDICAID | 44428 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 44428 | 01 | FL | BCBS OF FLORIDA | OTHER | 285354 | 01 | FL | AVMED | OTHER | 050063733 | 01 | FL | RAILROAD MEDICARE | OTHER |