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General NPI Number Information
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NPI Number | 1952951154
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Entity Type | Organization
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Legal Business Name | PREMIER RADIOLOGY WISCONSIN, LLC
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Dates
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Enumeration Date | 09/19/2019
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 10180 WASHINGTON AVE STE 101
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City | MOUNT PLEASANT
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State | WI
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Zip | 53177-1604
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Country | US
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Telephone | 414-973-7830
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Fax | 414-793-7831
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Provider Business Mailing Address
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Address Line | PO BOX 713302
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City | CHICAGO
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State | IL
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Zip | 60677-1320
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | MICHAEL MCCULLOUGH
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Credential |
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Telephone | 414-465-3736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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