Healthcare Provider Details

I. General information

NPI: 1902803562
Provider Name (Legal Business Name): WILLIAM HANES MCCUSKEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 BROADWAY
FORT MYERS FL
33901-8005
US

IV. Provider business mailing address

3660 BROADWAY
FORT MYERS FL
33901-8005
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-2316
  • Fax: 239-834-6106
Mailing address:
  • Phone: 239-936-2316
  • Fax: 239-834-6106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME103541
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number34395
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34395
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101245169
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: