Provider Demographics
NPI:1104847086
Name:MILWAUKEE DIAGNOSTIC SERVICES SC
Entity Type:Organization
Organization Name:MILWAUKEE DIAGNOSTIC SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIBSOHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-744-6300
Mailing Address - Street 1:1233 N MAYFAIR RD
Mailing Address - Street 2:SUITE #201
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3255
Mailing Address - Country:US
Mailing Address - Phone:414-774-6300
Mailing Address - Fax:
Practice Address - Street 1:1233 N MAYFAIR RD
Practice Address - Street 2:SUITE #201
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3255
Practice Address - Country:US
Practice Address - Phone:414-774-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30220700Medicaid