Basic Information
| Provider Information | |||||||||
| NPI: | 1821023961 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CT IMAGING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33164 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204991428 | ||||||||
| FaxNumber: | 9204995808 | ||||||||
| Practice Location | |||||||||
| Address1: | 744 S WEBSTER AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204333411 | ||||||||
| FaxNumber: | 9204995808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIETSCHE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9204333796 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 21267900 | 05 | WI | MEDICAID | DA1841 | 01 | RR MEDICARE | OTHER |