Healthcare Provider Details

I. General information

NPI: 1740271287
Provider Name (Legal Business Name): RADIATION ONCOLOGY OF WISCONSIN S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N LAKE DR RADIATION ONCOLOGY DEPT.
MILWAUKEE WI
53211-4507
US

IV. Provider business mailing address

PO BOX 1127
SHEBOYGAN WI
53082-1127
US

V. Phone/Fax

Practice location:
  • Phone: 414-291-1556
  • Fax: 414-291-1557
Mailing address:
  • Phone: 920-457-6750
  • Fax: 920-457-8350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DONNA LARUE
Title or Position: OFFICE MANAGER
Credential:
Phone: 920-457-6750