MEDICARE: KATHLENE A KUSIV D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	33267-021	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	33287	OTHER	WI	WIS LICENSE

General Provider Information

NPI Number	:	1073522637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLENE A KUSIV D.O.

Provider Business Mailing Address
First Line	:	1537 PARK PL STE 200
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-1974
Country	:	US
Telephone Number	:	920-498-8650
Fax Number	:	920-498-0945

Provider Business Practice Location Address
First Line	:	1537 PARK PL STE 200
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-1974
Country	:	US
Telephone Number	:	920-498-8650
Fax Number	:	920-498-0945

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	11/02/2010

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