MEDICARE: MADISON RAITH RD

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	133V00000X	Registered Dietitian	86434411	WI

General Provider Information

NPI Number	:	1891659843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON RAITH RD

Provider Business Mailing Address
First Line	:	6608 40TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-7054
Country	:	US
Telephone Number	:	262-358-2080
Fax Number	:

Provider Business Practice Location Address
First Line	:	731 N WATER ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-4101
Country	:	US
Telephone Number	:	414-207-4637
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2025
Last Update Date	:	12/15/2025

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