Provider Demographics
NPI:1477595742
Name:CUISON, MARYVIC CHERYL (DO)
Entity Type:Individual
Prefix:
First Name:MARYVIC
Middle Name:CHERYL
Last Name:CUISON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 673397
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3397
Mailing Address - Country:US
Mailing Address - Phone:866-898-7139
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:1500 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1849
Practice Address - Country:US
Practice Address - Phone:231-739-9341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010895207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114735100Medicaid
MI4839938Medicaid
MIMC010895OtherBCBS
MI4849200Medicaid
MI2648516Medicaid
MIE18671Medicare UPIN
MI4849200Medicaid
MIM60660062Medicare ID - Type Unspecified
P00253254Medicare PIN