Provider Demographics
NPI:1023753688
Name:PROHEALTH MEDICAL GROUP INC
Entity type:Organization
Organization Name:PROHEALTH MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REIMBURSEMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-928-4704
Mailing Address - Street 1:N17W24100 RIVERWOOD DR STE 250
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1177
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-928-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROHEALTH MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-28
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology