Provider Demographics
NPI:1942494273
Name:J DOUGLAS CUSICK, MD, INC
Entity Type:Organization
Organization Name:J DOUGLAS CUSICK, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:CUSICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-661-9537
Mailing Address - Street 1:4601 COLLEGE BLVD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1650
Mailing Address - Country:US
Mailing Address - Phone:913-661-0202
Mailing Address - Fax:913-661-0584
Practice Address - Street 1:4601 COLLEGE BLVD
Practice Address - Street 2:SUITE 222
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1650
Practice Address - Country:US
Practice Address - Phone:913-661-0202
Practice Address - Fax:913-661-0584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1001812086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO27458015OtherBCBS GROUP #