Provider Demographics
NPI:1669546347
Name:RADIOLOGY MERRILL SC
Entity type:Organization
Organization Name:RADIOLOGY MERRILL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:NEUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-338-6176
Mailing Address - Street 1:280 W RUSCO DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9780
Mailing Address - Country:US
Mailing Address - Phone:262-338-6176
Mailing Address - Fax:
Practice Address - Street 1:601 S CENTER AVE
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-3404
Practice Address - Country:US
Practice Address - Phone:262-338-6176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26317-020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32723000Medicaid
WI000037070Medicare ID - Type Unspecified
WI000037070Medicare PIN