Healthcare Provider Details

I. General information

NPI: 1770540130
Provider Name (Legal Business Name): KENOSHA RADIOLOGY CENTER LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10117 74TH ST SUITE 150
KENOSHA WI
53142-7533
US

IV. Provider business mailing address

10117 74TH ST SUITE 150
KENOSHA WI
53142-7533
US

V. Phone/Fax

Practice location:
  • Phone: 262-697-7770
  • Fax: 262-697-7771
Mailing address:
  • Phone: 262-697-7770
  • Fax: 262-697-7771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberXM310472
License Number StateWI

VIII. Authorized Official

Name: DR. JOHN S. PALLIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 262-697-7770