MEDICARE: DR. GARY JOSEPH FUSCIARDI PHD

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	103TC0700X	Clinical Psychologist	6301005314	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5088220	OTHER	MI	AETNA
2	042893	OTHER	MI	VALUE OPTIONS

General Provider Information

NPI Number	:	1245299361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY JOSEPH FUSCIARDI PHD

Provider Business Mailing Address
First Line	:	52480 SHELBY RD
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-3163
Country	:	US
Telephone Number	:	586-323-0696
Fax Number	:	586-731-8393

Provider Business Practice Location Address
First Line	:	8061 21 MILE RD
Second Line	:	SUITE #4
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48317-4311
Country	:	US
Telephone Number	:	586-323-0696
Fax Number	:	586-731-8393

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

Provider Enumeration Date	:	03/18/2006
Last Update Date	:	07/08/2007

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