Healthcare Provider Details

I. General information

NPI: 1861685133
Provider Name (Legal Business Name): RADIOLOGY WAUKESHA S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 HOSPITAL DR
WATERTOWN WI
53098-3303
US

IV. Provider business mailing address

18650 W CORPORATE DR SUITE 200
BROOKFIELD WI
53045-6344
US

V. Phone/Fax

Practice location:
  • Phone: 920-262-4659
  • Fax: 414-422-9620
Mailing address:
  • Phone: 262-641-6888
  • Fax: 414-422-9620

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: MR. VICTOR IAN CZARNECKI
Title or Position: BUSINESS MANAGER
Credential: MBA
Phone: 414-422-0780