Healthcare Provider Details

I. General information

NPI: 1215925839
Provider Name (Legal Business Name): MMC MRI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST SUITE 301
WAUKESHA WI
53188-3417
US

IV. Provider business mailing address

1111 DELAFIELD ST SUITE 301
WAUKESHA WI
53188-3417
US

V. Phone/Fax

Practice location:
  • Phone: 262-541-8020
  • Fax: 262-650-4398
Mailing address:
  • Phone: 262-541-8020
  • Fax: 262-650-4398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. BONNIE WIESMUELLER
Title or Position: DIRECTOR
Credential:
Phone: 262-541-8020