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General NPI Number Information
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NPI Number | 1700874435
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Entity Type | Individual
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Provider Name | EVELYN JANE CUSACK M.D.
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Gender | Female
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Dates
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Enumeration Date | 10/06/2005
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Last Update Date | 12/30/2016
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Provider Practice Location Address
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Address Line | 29 HOSPITAL PLAZA SUITE 502
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City | STAMFORD
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State | CT
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Zip | 06902-3602
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Country | US
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Telephone | 203-348-7410
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Fax | 203-961-8488
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Provider Business Mailing Address
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Address Line | 29 HOSPITAL PLAZA SUITE 502
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City | STAMFORD
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State | CT
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Zip | 06902-3602
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Country | US
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Telephone | 203-348-7410
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Fax | 203-961-8488
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 41998
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License Number State | CT
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