Provider Demographics
NPI:1235252024
Name:FOND DU LAC COUNTY
Entity Type:Organization
Organization Name:FOND DU LAC COUNTY
Other - Org Name:FOND DU LAC COUNTY DCP ACUTE UNIT
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10062400Medicaid
WI524025Medicare Oscar/Certification