Healthcare Provider Details

I. General information

NPI: 1346265915
Provider Name (Legal Business Name): LAKESHORE RADIOLOGY ASSOCIATES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 WESTERN AVE
MANITOWOC WI
54221-1450
US

IV. Provider business mailing address

2300 WESTERN AVE
MANITOWOC WI
54220-3712
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-3800
  • Fax:
Mailing address:
  • Phone: 920-320-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier32729200
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name: MATTHEW J KOEBERL
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 920-320-3800