Basic Information
| Provider Information | |||||||||
| NPI: | 1609139419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST IMAGING PROFESSIONALS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 686 | ||||||||
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| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544020686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127248477 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2233 W DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606228151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127702000 | ||||||||
| FaxNumber: | 6305718810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2012 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | CASSIN | ||||||||
| AuthorizedOfficialFirstName: | NAOMI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | AVP, PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 3127248477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.