MEDICARE: DANIELLE KUSSEROW BERSABE M.D.

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	207R00000X	Internal Medicine Physician	26567	MS

General Provider Information

NPI Number	:	1003177593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE KUSSEROW BERSABE M.D.

Provider Business Mailing Address
First Line	:	2200 BERQUIST DR
Second Line	:	INTERNAL MEDICINE CLINIC
City	:	LACKLAND AFB
State	:	TX
Zip	:	78233
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 CEDAR LAKE RD STE R
Second Line	:
City	:	BILOXI
State	:	MS
Zip	:	39532-2107
Country	:	US
Telephone Number	:	228-207-0260
Fax Number	:

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

Provider Enumeration Date	:	05/31/2012
Last Update Date	:	12/19/2023

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