Provider Demographics
NPI:1851554083
Name:STEVEN J MCCUISTON MD PC
Entity type:Organization
Organization Name:STEVEN J MCCUISTON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCCUISTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-493-4620
Mailing Address - Street 1:4905A LAVISTA RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4437
Mailing Address - Country:US
Mailing Address - Phone:770-493-4620
Mailing Address - Fax:770-270-5301
Practice Address - Street 1:4905A LAVISTA RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4437
Practice Address - Country:US
Practice Address - Phone:770-493-4620
Practice Address - Fax:770-270-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11BDCCNMedicare PIN
GAE91374Medicare UPIN