Provider Demographics
NPI:1821416454
Name:MARK P CARUSO MD
Entity Type:Organization
Organization Name:MARK P CARUSO MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-789-4949
Mailing Address - Street 1:713 BROADWAY ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1465
Mailing Address - Country:US
Mailing Address - Phone:606-789-4949
Mailing Address - Fax:
Practice Address - Street 1:713 BROADWAY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1465
Practice Address - Country:US
Practice Address - Phone:606-789-4949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26513207R00000X
KYPA804363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty