MEDICARE: RADIATION ONCOLOGY OF WISCONSIN S C

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0203X	Therapeutic Radiology Physician
2	2085R0001X	Radiation Oncology Physician

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CJ6385	OTHER	WI	RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1740271287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIATION ONCOLOGY OF WISCONSIN S C

Provider Business Mailing Address
First Line	:	PO BOX 1127
Second Line	:
City	:	SHEBOYGAN
State	:	WI
Zip	:	53082-1127
Country	:	US
Telephone Number	:	920-457-6750
Fax Number	:	920-457-8350

Provider Business Practice Location Address
First Line	:	2350 N LAKE DR
Second Line	:	RADIATION ONCOLOGY DEPT.
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4507
Country	:	US
Telephone Number	:	414-291-1556
Fax Number	:	414-291-1557

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DONNA LARUE
Credential	:
Telephone Number	:	920-457-6750

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	04/20/2008

2350 N LAKE DR , SUITE 502
MILWAUKEE, WI
53211-4507

Practice Phone: 414-271-3300
Practice Fax: 414-271-5549