Provider Demographics
NPI:1427165331
Name:MEDICAL DIAGNOSTIC IMAGING LLC
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTIC IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-282-4100
Mailing Address - Street 1:6150 WEST LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220
Mailing Address - Country:US
Mailing Address - Phone:414-282-4100
Mailing Address - Fax:414-282-4108
Practice Address - Street 1:6150 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4608
Practice Address - Country:US
Practice Address - Phone:414-282-4100
Practice Address - Fax:414-282-4105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32896000Medicaid
WI000092115Medicare PIN