Basic Information
| Provider Information | |||||||||
| NPI: | 1356321715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERIPATH MILWAUKEE SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 S UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539163027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208877181 | ||||||||
| FaxNumber: | 4144762975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 11/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6105503000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 32812800 | 05 | WI | MEDICAID | 52D0391842 | 01 | WI | CLIA | OTHER | 32812700 | 05 | WI | MEDICAID | 32869100 | 05 | WI | MEDICAID | 52D1004935 | 01 | WI | CLIA | OTHER | 52D0390963 | 01 | WI | CLIA | OTHER | 52D1019615 | 01 | WI | CLIA | OTHER | 52D0397949 | 01 | WI | CLIA | OTHER | 52D0662006 | 01 | WI | CLIA | OTHER | 32868900 | 05 | WI | MEDICAID | 32869000 | 05 | WV | MEDICAID | 52D0388186 | 01 | WI | CLIA | OTHER | 52D0390458 | 01 | WI | CLIA | OTHER |