Healthcare Provider Details

I. General information

NPI: 1225176233
Provider Name (Legal Business Name): MEDICAL DIAGNOSTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 SOUTH STREET DEPARTMENT OF PATHOLOGY
LAFAYETTE IN
47903
US

IV. Provider business mailing address

18650 W CORPORATE DRIVE SUITE 200
BROOKFIELD WI
53045
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-7201
  • Fax: 765-448-2921
Mailing address:
  • Phone: 262-641-5143
  • Fax: 262-641-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MARIO R CONTRERAS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 765-446-7201