Basic Information
| Provider Information | |||||||||
| NPI: | 1629004098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL WISCONSIN RADIOLOGISTS SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3410 STANLEY ST | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544811325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153441234 | ||||||||
| FaxNumber: | 7153446367 | ||||||||
| Practice Location | |||||||||
| Address1: | 3410 STANLEY ST | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544811325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153441234 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | MUNAGIAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7153441234 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 32730300 | 05 | WI | MEDICAID |