=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164494142
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOPATHOLOGY OF WISCONSIN SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2006
-----------------------------------------------------
Last Update Date | 09/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12805 W BURLEIGH RD SUITE 200
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53005-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-797-6434
-----------------------------------------------------
Fax | 262-797-6429
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14275 MIDWAY RD STE 400
-----------------------------------------------------
City | ADDISON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75001-3661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-932-8018
-----------------------------------------------------
Fax | 610-271-4245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DARREN THOMAS WHEELER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 702-733-7866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 52D0661946
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------