MEDICARE: DR. KRISADA CHANBUSARAKUM 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	207T00000X	Neurological Surgery Physician	20690	WI

General Provider Information

NPI Number	:	1548221849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISADA CHANBUSARAKUM M.D.

Provider Business Mailing Address
First Line	:	5005 COTTAGE GROVE RD
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53716-1309
Country	:	US
Telephone Number	:	608-221-8999
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 S PARK ST
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53715-1348
Country	:	US
Telephone Number	:	608-255-4223
Fax Number	:	608-255-4449

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

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	07/08/2007

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