MEDICARE: MILWAUKEE CENTER FOR DIAGNOSTIC IMAGING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1093782435
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILWAUKEE CENTER FOR DIAGNOSTIC IMAGING LLC

Provider Business Mailing Address
First Line	:	PO BOX 2088
Second Line	:	DEPT 4058
City	:	MILWAUKEE
State	:	WI
Zip	:	53201-2088
Country	:	US
Telephone Number	:	952-542-8553
Fax Number	:	952-513-6880

Provider Business Practice Location Address
First Line	:	2445 NORTH MAYFAIR RD
Second Line	:	SUITE 100
City	:	WAUWATOSA
State	:	WI
Zip	:	53226
Country	:	US
Telephone Number	:	414-774-7226
Fax Number	:	414-774-6004

Authorized Official
Title or Position	:	OFFICER ON THE BOARD ASST SECRETARY
Name	:	DONALD D JACOBSEN
Credential	:
Telephone Number	:	952-543-6500

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	08/22/2020

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