Basic Information
| Provider Information | |||||||||
| NPI: | 1093739427 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUSSA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | FLORIAN | ||||||||
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| Credential: | MD AODAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 MAPLE LN | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548063626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855500 | ||||||||
| FaxNumber: | 7156855102 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 MAPLE LN | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548063626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855500 | ||||||||
| FaxNumber: | 7156855102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | 17169 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 207RA0401X | 17169 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2632839 10 | 01 | WI | M MA | OTHER | 391662030 | 01 | ASHLAND CTY | OTHER | 4060137 | 01 | DEA AH | OTHER | 31192600 | 05 | WI | MEDICAID | 0979600000 | 01 | BAYFIELD CTY | OTHER |