Healthcare Provider Details

I. General information

NPI: 1366776601
Provider Name (Legal Business Name): FLEMING DERMATOPATHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 N WATER ST #500
MILWAUKEE WI
53202-2085
US

IV. Provider business mailing address

PO BOX 1003
WICHITA KS
67201-1003
US

V. Phone/Fax

Practice location:
  • Phone: 414-446-3450
  • Fax:
Mailing address:
  • Phone: 800-425-6236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW G FLEMING
Title or Position: PRESIDENT
Credential: MD
Phone: 414-446-3450