Provider Demographics
NPI:1043358492
Name:FOND DU LAC COUNTY DCP CASE MANAGEMENT
Entity Type:Organization
Organization Name:FOND DU LAC COUNTY DCP CASE MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:R
Authorized Official - Last Name:MUSUNURU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-929-3500
Mailing Address - Street 1:459 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4505
Mailing Address - Country:US
Mailing Address - Phone:920-929-3500
Mailing Address - Fax:920-929-3129
Practice Address - Street 1:459 E 1ST ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4505
Practice Address - Country:US
Practice Address - Phone:920-929-3500
Practice Address - Fax:920-929-3129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43072100Medicaid