Provider Demographics
NPI:1356397616
Name:NEWISCONSIN MRI CENTER OF GREEN BAY LLC
Entity type:Organization
Organization Name:NEWISCONSIN MRI CENTER OF GREEN BAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-431-7120
Mailing Address - Street 1:2141 LIME KILN RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6215
Mailing Address - Country:US
Mailing Address - Phone:920-431-7120
Mailing Address - Fax:920-431-7537
Practice Address - Street 1:2141 LIME KILN RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6215
Practice Address - Country:US
Practice Address - Phone:920-431-7120
Practice Address - Fax:920-431-7537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21297900Medicaid
WI1059612001OtherAMERICHOICE MEDICAID
WI=========012OtherBC/BS PROVIDER ID NUMBER
WI92645Medicare PIN
WI92545Medicare PIN
P00302347Medicare PIN