Provider Demographics
NPI:1679890297
Name:MOLECULAR IMAGING ALLIANCE OF MILWAUKEE, LLC
Entity Type:Organization
Organization Name:MOLECULAR IMAGING ALLIANCE OF MILWAUKEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-403-1401
Mailing Address - Street 1:11226 W LAPHAM ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3806
Mailing Address - Country:US
Mailing Address - Phone:414-395-1941
Mailing Address - Fax:414-302-7064
Practice Address - Street 1:9200 LEESGATE RD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5173
Practice Address - Country:US
Practice Address - Phone:502-403-1401
Practice Address - Fax:502-403-1451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-21
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100015024Medicaid
WIWI2046Medicare PIN