Healthcare Provider Details

I. General information

NPI: 1851736953
Provider Name (Legal Business Name): SCOTT R. CUSHMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST 690 NORTH
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

123 SUMMER ST 690 NORTH
WORCESTER MA
01608-1216
US

V. Phone/Fax

Practice location:
  • Phone: 508-363-9530
  • Fax:
Mailing address:
  • Phone: 508-363-9530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number268197
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: