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NPI Code Detail

MEDICARE: LAKESIDE DIAGNOSTIC IMAGING CENTER, LLC

MEDICARE: LAKESIDE DIAGNOSTIC IMAGING CENTER, 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
12085R0202XDiagnostic Radiology Physician

Other Identifiers

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

General Provider Information

NPI Number : 1639111016
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKESIDE DIAGNOSTIC IMAGING CENTER, LLC
Provider Business Mailing Address
First Line : 4601 N OAKLAND AVE
Second Line :
City : SHOREWOOD
State : WI
Zip : 53211-1232
Country : US
Telephone Number : 414-964-4601
Fax Number : 414-964-4616
Provider Business Practice Location Address
First Line : 4601 N OAKLAND AVE
Second Line :
City : SHOREWOOD
State : WI
Zip : 53211-1232
Country : US
Telephone Number : 414-964-4601
Fax Number : 414-964-4616
Authorized Official
Title or Position : AUTHORIZED OFFICIAL
Name : BRUCE W. CARDONE
Credential : MD
Telephone Number : 414-964-4601
Provider Enumeration Date : 06/12/2006
Last Update Date : 03/25/2008

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Directions to “LAKESIDE DIAGNOSTIC IMAGING CENTER, LLC ” Practice Location

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