Provider Demographics
NPI:1760416895
Name:RADIOLOGY CHARTERED
Entity Type:Organization
Organization Name:RADIOLOGY CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANIECE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRABANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-499-2766
Mailing Address - Street 1:1789 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3243
Mailing Address - Country:US
Mailing Address - Phone:920-499-1428
Mailing Address - Fax:920-499-7080
Practice Address - Street 1:1789 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3243
Practice Address - Country:US
Practice Address - Phone:920-499-1428
Practice Address - Fax:920-499-7080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIC04047OtherRR MEDICARE
WI32725000Medicaid
WI000007273OtherPTAN
WI32725000Medicaid