=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861436719
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN MICHAEL LAMANCUSO MD, FACP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2006
-----------------------------------------------------
Last Update Date | 01/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 S MAIN ST SUITE 151
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14701-6626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-483-0113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 S MAIN ST SUITE 151
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14701-6626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 142873-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------