Basic Information
| Provider Information | |||||||||
| NPI: | 1780667543 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSSAK | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 QUEEN ST | ||||||||
| Address2: | FAMILY PRACTICE 1 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607700 | ||||||||
| FaxNumber: | 5088607929 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 QUEEN ST | ||||||||
| Address2: | FAMILY PRACTICE 1 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607700 | ||||||||
| FaxNumber: | 5088607929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2005 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 155167 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0109061 | 05 | MA | MEDICAID |