Healthcare Provider Details

I. General information

NPI: 1225087224
Provider Name (Legal Business Name): IHC-KENOSHA RADIOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 76TH STREET UHS ST CATHERINES CAMPUS
PLEASANT PRAIRIE WI
53158-1984
US

IV. Provider business mailing address

111 E WISCONSIN AVE SUITE 2000
MILWAUKEE WI
53202-4815
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-6720
  • Fax: 414-290-6755
Mailing address:
  • Phone: 414-290-6720
  • Fax: 414-290-6755

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: KATHLEEN KONDAS
Title or Position: OFFICER
Credential:
Phone: 954-838-2371