Healthcare Provider Details

I. General information

NPI: 1629442181
Provider Name (Legal Business Name): DYSPHAGIA TESTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2015
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10638 HIDDEN CREEK DR
MEQUON WI
53092-8538
US

IV. Provider business mailing address

10638 HIDDEN CREEK DR
MEQUON WI
53092-8538
US

V. Phone/Fax

Practice location:
  • Phone: 262-442-2152
  • Fax:
Mailing address:
  • Phone: 262-442-2152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number33675-20
License Number StateWI

VIII. Authorized Official

Name: DR. SUSAN JOAN RIEGG
Title or Position: OWNER
Credential: MD
Phone: 262-442-2152