MEDICARE: DR. EVELYN JANE 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	207RC0000X	Cardiovascular Disease Physician	41998	CT

General Provider Information

NPI Number	:	1700874435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVELYN JANE CUSACK M.D.

Provider Business Mailing Address
First Line	:	29 HOSPITAL PLAZA
Second Line	:	SUITE 502
City	:	STAMFORD
State	:	CT
Zip	:	06902-3602
Country	:	US
Telephone Number	:	203-348-7410
Fax Number	:	203-961-8488

Provider Business Practice Location Address
First Line	:	29 HOSPITAL PLAZA
Second Line	:	SUITE 502
City	:	STAMFORD
State	:	CT
Zip	:	06902-3602
Country	:	US
Telephone Number	:	203-348-7410
Fax Number	:	203-961-8488

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

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	12/30/2016

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