Provider Demographics
NPI:1285677377
Name:MCCUSKER, KEVIN TRACY (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TRACY
Last Name:MCCUSKER
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 1:2020 N. 19TH ST.
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0821
Mailing Address - Country:US
Mailing Address - Phone:857-345-0127
Mailing Address - Fax:413-543-7962
Practice Address - Street 1:2001 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-8658
Practice Address - Country:US
Practice Address - Phone:781-848-2600
Practice Address - Fax:781-952-2385
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91132207RP1001X
MA234398207RP1001X
IDM-12655207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG94953Medicare UPIN
MA000497001Medicare PIN
C63817Medicare UPIN