Provider Demographics
NPI:1386833051
Name:MCCUSKER, MICHAEL (RPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MCCUSKER
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W SHELL CREEK RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MINONG
Mailing Address - State:WI
Mailing Address - Zip Code:54859-9302
Mailing Address - Country:US
Mailing Address - Phone:715-466-2369
Mailing Address - Fax:715-466-2160
Practice Address - Street 1:600 W SHELL CREEK RD
Practice Address - Street 2:SUITE 2
Practice Address - City:MINONG
Practice Address - State:WI
Practice Address - Zip Code:54859-9302
Practice Address - Country:US
Practice Address - Phone:715-466-2369
Practice Address - Fax:715-466-2160
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3070024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0003647OtherTRICARE CLAIMS
391612886013OtherBCBSWI