Provider Demographics
NPI:1962510800
Name:MANCUSO, MICHAEL GREGORY (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GREGORY
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33001 SOLON RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-2839
Mailing Address - Country:US
Mailing Address - Phone:440-248-2955
Mailing Address - Fax:440-248-5717
Practice Address - Street 1:34055 SOLON RD STE 108
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2600
Practice Address - Country:US
Practice Address - Phone:440-248-2955
Practice Address - Fax:440-248-5717
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043115174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0515188Medicaid
OHMA0502823Medicare ID - Type Unspecified
OH0515188Medicaid