Provider Demographics
NPI:1316302797
Name:PISANG LLC
Entity type:Organization
Organization Name:PISANG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSUMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-209-1424
Mailing Address - Street 1:PO BOX 3602
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54602-3602
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-5741
Practice Address - Street 1:37868 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-8416
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:702-453-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52325-20207R00000X
MN54950207R00000X
208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty