Healthcare Provider Details

I. General information

NPI: 1639111016
Provider Name (Legal Business Name): LAKESIDE DIAGNOSTIC IMAGING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 N OAKLAND AVE
SHOREWOOD WI
53211-1232
US

IV. Provider business mailing address

4601 N OAKLAND AVE
SHOREWOOD WI
53211-1232
US

V. Phone/Fax

Practice location:
  • Phone: 414-964-4601
  • Fax: 414-964-4616
Mailing address:
  • Phone: 414-964-4601
  • Fax: 414-964-4616

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: BRUCE W. CARDONE
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 414-964-4601