Provider Demographics
NPI:1114141744
Name:DAWN B MANCUSO, MD, LLC
Entity Type:Organization
Organization Name:DAWN B MANCUSO, MD, LLC
Other - Org Name:HERITAGE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-990-8446
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-0617
Mailing Address - Country:US
Mailing Address - Phone:256-990-8446
Mailing Address - Fax:256-461-0393
Practice Address - Street 1:12205 COUNTY LINE RD
Practice Address - Street 2:SUITE B
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-7719
Practice Address - Country:US
Practice Address - Phone:256-990-8446
Practice Address - Fax:256-461-0393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00015990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529910550Medicaid
AL051506404OtherMANCUSO BCBS
AL529910550Medicaid
ALE91320Medicare UPIN
AL051551297Medicare ID - Type UnspecifiedMANCUSO