Basic Information
| Provider Information | |||||||||
| NPI: | 1316302797 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PISANG LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3602 | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546023602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Practice Location | |||||||||
| Address1: | 37868 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | PRAIRIE DU CHIEN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 538218416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2015 | ||||||||
| LastUpdateDate: | 12/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | KUSUMA | ||||||||
| AuthorizedOfficialFirstName: | BENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3162091424 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 54950 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 52325-20 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.