Healthcare Provider Details

I. General information

NPI: 1285211565
Provider Name (Legal Business Name): AUSTIN SCOTT CUSICK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CABELA DR
TRIADELPHIA WV
26059-1044
US

IV. Provider business mailing address

PO BOX 746750
ATLANTA GA
30374-6750
US

V. Phone/Fax

Practice location:
  • Phone: 681-618-1011
  • Fax:
Mailing address:
  • Phone: 681-618-1101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number4920
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: