Provider Demographics
NPI:1306201330
Name:ELITE EXTREMITY MRI OF WISCONSIN, LLC
Entity Type:Organization
Organization Name:ELITE EXTREMITY MRI OF WISCONSIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUDGATIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-496-3838
Mailing Address - Street 1:1050 MILWAUKEE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1380
Mailing Address - Country:US
Mailing Address - Phone:262-758-6155
Mailing Address - Fax:262-758-6145
Practice Address - Street 1:4931 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2652
Practice Address - Country:US
Practice Address - Phone:414-249-3250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty