Provider Demographics
NPI:1538127816
Name:MRI & IMAGING OF WISCONSIN INC
Entity Type:Organization
Organization Name:MRI & IMAGING OF WISCONSIN INC
Other - Org Name:KENOSHA DIAGNOSTIC IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:PO BOX 934978
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-4978
Mailing Address - Country:US
Mailing Address - Phone:866-659-1211
Mailing Address - Fax:336-774-1751
Practice Address - Street 1:8500 75TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8213
Practice Address - Country:US
Practice Address - Phone:262-697-9800
Practice Address - Fax:262-697-8450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21268400Medicaid
WI488503OtherBC
470001862OtherMEDICARE RR
WI488503OtherBC