Provider Demographics
NPI:1932580909
Name:CUSACK, MELINDA MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:MICHELLE
Last Name:CUSACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:MECHELLE
Other - Last Name:MAILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20095 GILBERT RD
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2365
Mailing Address - Country:US
Mailing Address - Phone:231-592-1360
Mailing Address - Fax:231-592-1361
Practice Address - Street 1:20095 GILBERT RD
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2365
Practice Address - Country:US
Practice Address - Phone:231-592-1360
Practice Address - Fax:231-592-1361
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301500878207Q00000X
IN11018213A207Q00000X, 390200000X
MI4301111076390200000X
IN01088779A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program