Basic Information
| Provider Information | |||||||||
| NPI: | 1215925839 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MMC MRI LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 DELAFIELD ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531883417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625418020 | ||||||||
| FaxNumber: | 2626504398 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 DELAFIELD ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531883417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625418020 | ||||||||
| FaxNumber: | 2626504398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WIESMUELLER | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2625418020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | 21268000 | 05 | WI | MEDICAID |