MEDICARE: SERIC CUSICK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	A94644	CA

General Provider Information

NPI Number	:	1033142914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERIC CUSICK MD

Provider Business Mailing Address
First Line	:	1713 S OLA VIS
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4343
Country	:	US
Telephone Number	:	707-812-2983
Fax Number	:

Provider Business Practice Location Address
First Line	:	1713 S OLA VIS
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4343
Country	:	US
Telephone Number	:	707-812-2983
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	03/03/2016

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