Provider Demographics
NPI:1538248760
Name:OPEN MRI OF SHEBOYGAN LLC
Entity type:Organization
Organization Name:OPEN MRI OF SHEBOYGAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KAMKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-208-9000
Mailing Address - Street 1:1414 NORTH TAYLOR
Mailing Address - Street 2:OPEN MRI OF SHEBOYGAN
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081
Mailing Address - Country:US
Mailing Address - Phone:920-208-9000
Mailing Address - Fax:920-208-9001
Practice Address - Street 1:1414 NORTH TAYLOR
Practice Address - Street 2:OPEN MRI OF SHEBOYGAN
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-208-9000
Practice Address - Fax:920-208-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21258500Medicaid
WI92130Medicare ID - Type Unspecified