=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427102631
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN L HUSSLEIN PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8802 W BECHER ST
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-541-1118
-----------------------------------------------------
Fax | 414-541-3066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3645 HIGH RIDGE DR
-----------------------------------------------------
City | RICHFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-628-9248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 377019
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------