Provider Demographics
NPI:1184673964
Name:PEDIATRIC RADIOLOGIC SERVICES SC
Entity Type:Organization
Organization Name:PEDIATRIC RADIOLOGIC SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING CHIEF
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-266-1640
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122
Mailing Address - Country:US
Mailing Address - Phone:262-821-9131
Mailing Address - Fax:262-821-9132
Practice Address - Street 1:9000 WEST WISCONSIN AVENUE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53201
Practice Address - Country:US
Practice Address - Phone:414-266-1640
Practice Address - Fax:414-266-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI326-79000Medicaid
WI01-630Medicare ID - Type Unspecified