Provider Demographics
NPI:1003962481
Name:FUSCO, MICHAEL CARL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CARL
Last Name:FUSCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14528 S OUTER 40
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5785
Mailing Address - Country:US
Mailing Address - Phone:314-214-8100
Mailing Address - Fax:314-214-8233
Practice Address - Street 1:14528 S OUTER 40
Practice Address - Street 2:SUITE 300
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5785
Practice Address - Country:US
Practice Address - Phone:314-214-8100
Practice Address - Fax:314-214-8233
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3H26207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL333410LMedicaid
D36880Medicare ID - Type Unspecified
IL333410LMedicaid