MEDICARE: CARRIE ANN R CUSACK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	MD422137	PA
2	207ND0900X	Dermatopathology Physician	MD422137	PA
3	207N00000X	Dermatology Physician	25MA07815500	NJ
4	207ND0900X	Dermatopathology Physician	25MA07815500	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649238775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE ANN R CUSACK M.D.

Provider Business Mailing Address
First Line	:	1601 CHERRY ST
Second Line	:	SUITE 11511
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1320
Country	:	US
Telephone Number	:	215-255-7822
Fax Number	:	215-255-7825

Provider Business Practice Location Address
First Line	:	219 N BROAD ST
Second Line	:	4TH FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-1519
Country	:	US
Telephone Number	:	215-762-5550
Fax Number	:	215-762-5570

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	08/31/2016

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Directions to “ CARRIE ANN R CUSACK M.D.” Practice Location

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