Provider Demographics
NPI:1851625735
Name:KENNETH RASKIN MD SC
Entity Type:Organization
Organization Name:KENNETH RASKIN MD SC
Other - Org Name:BODYLOGICMD OF MILWAUKEE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RASKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-278-3693
Mailing Address - Street 1:9000 W CHESTER ST STE 210
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1373
Mailing Address - Country:US
Mailing Address - Phone:877-278-3693
Mailing Address - Fax:262-317-9311
Practice Address - Street 1:115 S 84TH ST
Practice Address - Street 2:SUITE 175
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-1472
Practice Address - Country:US
Practice Address - Phone:877-278-3693
Practice Address - Fax:877-278-3694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45098-020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty