Basic Information
| Provider Information | |||||||||
| NPI: | 1275670291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUSICK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MHSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229069007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 JEFFERSON PARK AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229033363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349245485 | ||||||||
| FaxNumber: | 4342449436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD-439428 | PA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 0101269475 | VA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | MD-439428 | PA | N | 207WX0107X | 0101269475 | VA | Y |
ID Information
| ID | Type | State | Issuer | Description | 102474527 | 05 | PA | MEDICAID |