Provider Demographics
NPI:1851588362
Name:JUNGSIL K CUSIMANO MD PC
Entity Type:Organization
Organization Name:JUNGSIL K CUSIMANO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:VERNOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-584-4104
Mailing Address - Street 1:68 OAK ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4625
Mailing Address - Country:US
Mailing Address - Phone:607-238-1041
Mailing Address - Fax:
Practice Address - Street 1:68 OAK ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4625
Practice Address - Country:US
Practice Address - Phone:607-238-1041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218013-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH25287Medicare UPIN