1093779647 NPI number — DR. DAVID A CUSICK M.D.

Table of content: DR. DAVID A CUSICK M.D. (NPI 1093779647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093779647 NPI number — DR. DAVID A CUSICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUSICK
Provider First Name:
DAVID
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093779647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13011 S 104TH AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALOS PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60464-1508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-478-3600
Provider Business Mailing Address Fax Number:
708-478-3552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3231 EUCLID AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
BERWYN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60402-3471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-783-2055
Provider Business Practice Location Address Fax Number:
708-783-2181
Provider Enumeration Date:
04/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  036084799 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060056549 . This is a "RAILROAD MEDICARE KANKAKE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 060042343 . This is a "RAILROAD MEDICARE COOK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: L68227 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CD8033 . This is a "RAILROAD MEDICARE GROUP PTAN NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CG1672 . This is a "RAILROAD MEDICARE GROUP PTAN NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: L57370 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CN2703 . This is a "RAILROAD MEDICARE GROUP PTAN NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 01621208 . This is a "BLUECROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036084799 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 416810 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 060053215 . This is a "RAILROAD MEDICARE WILL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1508810086 . This is a "GROUP NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 236550 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: L70143 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 236551 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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