Provider Demographics
NPI:1063036408
Name:COULEE DIAGNOSTIC RADIOLOGY INC
Entity Type:Organization
Organization Name:COULEE DIAGNOSTIC RADIOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OMOBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-518-3406
Mailing Address - Street 1:807 BARSON CT
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-3603
Mailing Address - Country:US
Mailing Address - Phone:608-518-3406
Mailing Address - Fax:
Practice Address - Street 1:1580 HERITAGE BLVD
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-9418
Practice Address - Country:US
Practice Address - Phone:608-518-3406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-01
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIF37837Medicaid
WI32447500Medicaid