MEDICARE: MCMC RADIOLOGY SERVICES, 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	261QR0200X	Radiology Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295784726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCMC RADIOLOGY SERVICES, LLC

Provider Business Mailing Address
First Line	:	5100 MONTOUR RD
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-5016
Country	:	US
Telephone Number	:	208-584-3526
Fax Number	:

Provider Business Practice Location Address
First Line	:	5310 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2239
Country	:	US
Telephone Number	:	414-873-7000
Fax Number	:	414-873-8632

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. ROBERT C. HELENIAK
Credential	:
Telephone Number	:	208-584-3526

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	08/22/2020

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