MEDICARE: PREMIER RADIOLOGY WISCONSIN, 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

General Provider Information

NPI Number	:	1952951154
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER RADIOLOGY WISCONSIN, LLC

Provider Business Mailing Address
First Line	:	PO BOX 713302
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-1320
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10180 WASHINGTON AVE STE 101
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53177-1604
Country	:	US
Telephone Number	:	414-973-7830
Fax Number	:	414-793-7831

Authorized Official
Title or Position	:	CFO
Name	:	MICHAEL MCCULLOUGH
Credential	:
Telephone Number	:	414-465-3736

Provider Enumeration Date	:	09/19/2019
Last Update Date	:	01/22/2025

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