Provider Demographics
NPI:1164691986
Name:RADIATION ONCOLOGY OF WISCONSIN S C
Entity Type:Organization
Organization Name:RADIATION ONCOLOGY OF WISCONSIN S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:E
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-291-1556
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53082-1127
Mailing Address - Country:US
Mailing Address - Phone:920-457-6750
Mailing Address - Fax:920-457-8350
Practice Address - Street 1:13111 N PORT WASHINGTON RD
Practice Address - Street 2:ATTN: RADIATION ONCOLOGY DEPT.
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2416
Practice Address - Country:US
Practice Address - Phone:262-243-8384
Practice Address - Fax:920-243-8385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICJ6385OtherTRAVELERS RR MEDICARE
WI32896900Medicaid
WI32896900Medicaid
WICJ6385OtherTRAVELERS RR MEDICARE