Provider Demographics
NPI:1164494142
Name:DERMATOPATHOLOGY OF WISCONSIN SC
Entity type:Organization
Organization Name:DERMATOPATHOLOGY OF WISCONSIN SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-733-7866
Mailing Address - Street 1:14275 MIDWAY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3661
Mailing Address - Country:US
Mailing Address - Phone:214-932-8018
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:12805 W BURLEIGH RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-3111
Practice Address - Country:US
Practice Address - Phone:262-797-6434
Practice Address - Fax:262-797-6429
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIPATH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-03
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52D0661946291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164494142Medicaid
SD5585170Medicaid
WI32911800Medicaid
IA0765271Medicaid
ND14900Medicaid
MN749475100Medicaid
WI52D1105706OtherCLIA
IL=========001Medicaid
ND14900Medicaid
WI=========013OtherBCBS OF WI GROUP
MN749475100Medicaid
IL=========001Medicaid