Healthcare Provider Details

I. General information

NPI: 1194733634
Provider Name (Legal Business Name): JOSEPH V CUSUMANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 WATSON RD STE. LL2
SAINT LOUIS MO
63109-1251
US

IV. Provider business mailing address

750 S HANLEY RD APT. 52
SAINT LOUIS MO
63105-2670
US

V. Phone/Fax

Practice location:
  • Phone: 314-781-9711
  • Fax: 314-781-9768
Mailing address:
  • Phone: 314-781-9711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberR9583
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR9583
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: