Provider Demographics
NPI:1043217722
Name:CUSICK, THERESE ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESE
Middle Name:ELIZABETH
Last Name:CUSICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:551 N HILLSIDE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4923
Mailing Address - Country:US
Mailing Address - Phone:316-263-0296
Mailing Address - Fax:316-263-9523
Practice Address - Street 1:551 N HILLSIDE ST STE 201
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4923
Practice Address - Country:US
Practice Address - Phone:316-263-0296
Practice Address - Fax:316-263-9523
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0427649208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100357660AMedicaid
KS057928Medicare ID - Type Unspecified
KSH11200Medicare UPIN