Provider Demographics
NPI:1992919278
Name:BREAST DIAGNOSTIC CLINIC SC
Entity type:Organization
Organization Name:BREAST DIAGNOSTIC CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILBRATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-523-4800
Mailing Address - Street 1:W238 N1645 ROCKWOOD DRIVE
Mailing Address - Street 2:STE 100
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1148
Mailing Address - Country:US
Mailing Address - Phone:262-523-4800
Mailing Address - Fax:262-523-4805
Practice Address - Street 1:W238 N1645 ROCKWOOD DRIVE
Practice Address - Street 2:STE 100
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1148
Practice Address - Country:US
Practice Address - Phone:262-523-4800
Practice Address - Fax:262-523-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32691200Medicaid
WI104257OtherFDA CERTIFICATION