Provider Demographics
NPI:1073522637
Name:KUSIV, KATHLENE A (DO)
Entity Type:Individual
Prefix:
First Name:KATHLENE
Middle Name:A
Last Name:KUSIV
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 PARK PL STE 200
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1974
Mailing Address - Country:US
Mailing Address - Phone:920-498-8650
Mailing Address - Fax:920-498-0945
Practice Address - Street 1:1537 PARK PL STE 200
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1974
Practice Address - Country:US
Practice Address - Phone:920-498-8650
Practice Address - Fax:920-498-0945
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33267-021207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31862800Medicaid
WI33287OtherWIS LICENSE
E49599Medicare UPIN
WI33287OtherWIS LICENSE