1164494142 NPI number — DERMATOPATHOLOGY OF WISCONSIN SC

Table of content: (NPI 1164494142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164494142 NPI number — DERMATOPATHOLOGY OF WISCONSIN SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOPATHOLOGY OF WISCONSIN SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DERMPATH DIAGNOSTICS OF WI
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164494142
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7111 FAIRWAY DRIVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33418-4207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-712-6200
Provider Business Mailing Address Fax Number:
561-712-7349

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12805 W BURLEIGH RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53005-3111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-797-6434
Provider Business Practice Location Address Fax Number:
262-797-6429
Provider Enumeration Date:
02/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOLAN
Authorized Official First Name:
KRISTIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
866-697-8378

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  52D0661946 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1164494142 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14900 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52D1105706 . This is a "CLIA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 5585170 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 749475100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0765271 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32911800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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