Basic Information
| Provider Information | |||||||||
| NPI: | 1225461148 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | SNEAD | ||||||||
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| NameSuffix: | III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | CLINICAL CANCER CENTER BUILDING, 5TH FLOOR, STE. C5400 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148050812 | ||||||||
| FaxNumber: | 4148054369 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | CLINICAL CANCER CENTER BUILDING, 5TH FLOOR, STE. C5400 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148050812 | ||||||||
| FaxNumber: | 4148054369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2013 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 69768 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1225461148 | 05 | WI | MEDICAID |