Provider Demographics
NPI:1104834811
Name:PORTAGE RADIOLOGY, SC
Entity Type:Organization
Organization Name:PORTAGE RADIOLOGY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:N
Authorized Official - Last Name:MAGNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-742-4131
Mailing Address - Street 1:2817 NEW PINERY RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9257
Mailing Address - Country:US
Mailing Address - Phone:608-742-4131
Mailing Address - Fax:608-826-2710
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9257
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:608-826-2710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21266400Medicaid
WI21266400Medicaid