Basic Information
| Provider Information | |||||||||
| NPI: | 1639152770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST CLARE IMAGING SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6083561423 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/19/2019 | ||||||||
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 | 1043767 | 01 | WI | PHYS PLUS PROV # | OTHER | 567258 | 01 | WI | DEANCARE PROV # | OTHER | 21278400 | 05 | WI | MEDICAID |