Basic Information
| Provider Information | |||||||||
| NPI: | 1518978832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIEGEL | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 WESTHILL DR | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544013795 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 143 S GIBSON ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544511622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157482121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 21764 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 30422000 | 05 | WI | MEDICAID |