Provider Demographics
NPI:1518913573
Name:HALES CORNERS IMAGING, LLC
Entity Type:Organization
Organization Name:HALES CORNERS IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-514-8503
Mailing Address - Street 1:11716 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-2156
Mailing Address - Country:US
Mailing Address - Phone:414-778-3866
Mailing Address - Fax:414-778-3886
Practice Address - Street 1:11035 W FOREST HOME AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2541
Practice Address - Country:US
Practice Address - Phone:414-425-6602
Practice Address - Fax:414-425-6604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21269000Medicaid
P00321327OtherRAIL ROAD PIN
P00321327OtherRAIL ROAD PIN