Basic Information
| Provider Information | |||||||||
| NPI: | 1851383525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PUSATERI | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | E23570 POW WOW TRAIL | ||||||||
| Address2: | |||||||||
| City: | WATERSMEET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063584588 | ||||||||
| FaxNumber: | 9063584588 | ||||||||
| Practice Location | |||||||||
| Address1: | 3144 VANZILE RD | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154785180 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 29938-020 | WI | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 31543400 | 05 | WI | MEDICAID |