Provider Demographics
NPI:1770540130
Name:KENOSHA RADIOLOGY CENTER LLC.
Entity type:Organization
Organization Name:KENOSHA RADIOLOGY CENTER LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:PALLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-697-7770
Mailing Address - Street 1:10117 74TH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7533
Mailing Address - Country:US
Mailing Address - Phone:262-697-7770
Mailing Address - Fax:262-697-7771
Practice Address - Street 1:10117 74TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7533
Practice Address - Country:US
Practice Address - Phone:262-697-7770
Practice Address - Fax:262-697-7771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIXM310472261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21255800Medicaid
WID17032Medicare UPIN
WIF07877Medicare UPIN
WI92036Medicare ID - Type Unspecified
WIE68868Medicare UPIN
WIG95682Medicare UPIN
WI32090Medicare ID - Type Unspecified
WI21255800Medicaid
WIH01649Medicare UPIN