Healthcare Provider Details

I. General information

NPI: 1457325813
Provider Name (Legal Business Name): WILLIAM KUSSMAUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 N. BROAD STREET 15TH FLOOR
PHILADELPHIA PA
19107
US

IV. Provider business mailing address

230 N BROAD ST
PHILADELPHIA PA
19102-1121
US

V. Phone/Fax

Practice location:
  • Phone: 215-762-2640
  • Fax: 215-762-2642
Mailing address:
  • Phone: 215-255-3828
  • Fax: 215-255-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD020361E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: