Healthcare Provider Details

I. General information

NPI: 1033187927
Provider Name (Legal Business Name): JEREMY BOONE MCCUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2941 S RIDGE RD
GREEN BAY WI
54304-5517
US

IV. Provider business mailing address

2941 S RIDGE RD
GREEN BAY WI
54304-5517
US

V. Phone/Fax

Practice location:
  • Phone: 920-336-4096
  • Fax: 920-336-8093
Mailing address:
  • Phone: 920-336-4096
  • Fax: 920-336-8093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number9969A
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number53966
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number27947
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number42576-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: