Healthcare Provider Details

I. General information

NPI: 1184673964
Provider Name (Legal Business Name): PEDIATRIC RADIOLOGIC SERVICES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 WEST WISCONSIN AVENUE
MILWAUKEE WI
53201
US

IV. Provider business mailing address

PO BOX 230
ELM GROVE WI
53122
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-1640
  • Fax: 414-266-1625
Mailing address:
  • Phone: 262-821-9131
  • Fax: 262-821-9132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ROBERT G WELLS
Title or Position: OPERATING CHIEF
Credential: MD
Phone: 414-266-1640