1962510800 NPI number — MICHAEL GREGORY MANCUSO M.D.

Table of content: (NPI 1518724608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962510800 NPI number — MICHAEL GREGORY MANCUSO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANCUSO
Provider First Name:
MICHAEL
Provider Middle Name:
GREGORY
Provider Name Prefix Text:
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:
1962510800
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33001 SOLON RD
Provider Second Line Business Mailing Address:
SUITE 211
Provider Business Mailing Address City Name:
SOLON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44139-2839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-248-2955
Provider Business Mailing Address Fax Number:
440-248-5717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34055 SOLON RD STE 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOLON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44139-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-248-2955
Provider Business Practice Location Address Fax Number:
440-248-5717
Provider Enumeration Date:
08/29/2006

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: 174400000X , with the licence number:  35043115 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0515188 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".