Provider Demographics
NPI:1548263437
Name:KOUSAIE, GEORGE R (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:R
Last Name:KOUSAIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:603-740-4478
Mailing Address - Fax:
Practice Address - Street 1:67 CORPORATE DR, 3RD FL
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801
Practice Address - Country:US
Practice Address - Phone:603-610-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH18895207Q00000X
MEMD12938207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3099264Medicaid
MEMM305201OtherPTAN
ME121900099OtherMAINECARE SERVICING PROVIDER NUMBER
ME080190858OtherRAILROAD MEDICARE
ME121900099OtherMAINECARE SERVICING PROVIDER NUMBER