Basic Information
| Provider Information | |||||||||
| NPI: | 1639111016 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESIDE DIAGNOSTIC IMAGING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 N OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SHOREWOOD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532111232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149644601 | ||||||||
| FaxNumber: | 4149644616 | ||||||||
| Practice Location | |||||||||
| Address1: | 4601 N OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SHOREWOOD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532111232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149644601 | ||||||||
| FaxNumber: | 4149644616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 03/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | CARDONE | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4149644601 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 21258300 | 05 | WI | MEDICAID |