MEDICARE: IHC-KENOSHA RADIOLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	CG5950	OTHER	WI	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	020447700	OTHER	WI	FEDERAL BLACK LUNG PROGRA
2	120005850	OTHER	WI	WEA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	125363400	OTHER	WI	OWCP

General Provider Information

NPI Number	:	1225087224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IHC-KENOSHA RADIOLOGY, LLC

Provider Business Mailing Address
First Line	:	111 E WISCONSIN AVE
Second Line	:	SUITE 2000
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-4815
Country	:	US
Telephone Number	:	414-290-6720
Fax Number	:	414-290-6755

Provider Business Practice Location Address
First Line	:	9555 76TH STREET
Second Line	:	UHS ST CATHERINES CAMPUS
City	:	PLEASANT PRAIRIE
State	:	WI
Zip	:	53158-1984
Country	:	US
Telephone Number	:	414-290-6720
Fax Number	:	414-290-6755

Authorized Official
Title or Position	:	OFFICER
Name	:	KATHLEEN KONDAS
Credential	:
Telephone Number	:	954-838-2371

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	09/16/2019

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Directions to “IHC-KENOSHA RADIOLOGY, LLC ” Practice Location

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