Basic Information
| Provider Information | |||||||||
| NPI: | 1841229093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY ASSOCIATES OF APPLETON, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 E ENTERPRISE AVE | ||||||||
| Address2: | UNIT C | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207395642 | ||||||||
| FaxNumber: | 9209680259 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 E ENTERPRISE AVE | ||||||||
| Address2: | UNIT C | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207395642 | ||||||||
| FaxNumber: | 9209680259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 03/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | KNUDSON | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9207395642 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 32727000 | 05 | WI | MEDICAID |