Provider Demographics
NPI:1285601062
Name:SOUTHEASTERN WI RADIATION
Entity type:Organization
Organization Name:SOUTHEASTERN WI RADIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WINGATE
Authorized Official - Middle Name:FOSTER
Authorized Official - Last Name:CLAPPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-696-0696
Mailing Address - Street 1:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53187-0677
Mailing Address - Country:US
Mailing Address - Phone:262-696-0710
Mailing Address - Fax:262-696-5680
Practice Address - Street 1:N16W24131 RIVERWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:262-696-0696
Practice Address - Fax:262-696-0683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32828400Medicaid
68395Medicare ID - Type Unspecified