NPIMap

Organization Active NPI

Great Lakes Radiologists SC

  • Diagnostic Radiology Physician
  • New Berlin, WI
National Provider Identifier
1609800291
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
GREAT LAKES RADIOLOGISTS SC
Practice address
2875 S 171St St
New Berlin, WI 53151-3200
Phone
(262) 786-3107
Fax
(262) 780-0442
NPI assigned
Jul 10, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Thomas Grossman
Title
Chief Operating Officer
Phone
(262) 780-0357

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2085R0202X Primary

Addresses

Primary practice location

2875 S 171St St
New Berlin, WI 53151-3200

Mailing address

PO Box 511400
New Berlin, WI 53151-3200
Phone (262) 786-3107

Other identifiers 1

IdentifierTypeStateIssuer
32868800MedicaidWI

National Provider Directory

National Provider Directory

Locations

11025 W Mitchell St
West Allis, WI 53214
Phone (414) 546-9444

Practitioners & affiliated clinicians

Practitioners 47

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 47

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152489600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1609800291",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 511400",
            "city": "NEW BERLIN",
            "state": "WI",
            "postal_code": "531513200",
            "telephone_number": "262-786-3107",
            "fax_number": "262-780-0442"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2875 S 171ST ST",
            "city": "NEW BERLIN",
            "state": "WI",
            "postal_code": "531513200",
            "telephone_number": "262-786-3107",
            "fax_number": "262-780-0442"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES RADIOLOGISTS SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-10",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "GROSSMAN",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_title_or_position": "CHIEF OPERATING OFFICER",
        "authorized_official_telephone_number": "262-780-0357",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32868800",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in New Berlin, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.