Basic Information
| Provider Information | |||||||||
| NPI: | 1023112661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOX VALLEY PATHOLOGISTS SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
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| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | NEENAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207293000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | SENDELBACH-ELIZONDO | ||||||||
| AuthorizedOfficialFirstName: | KARLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 8002888325 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 52D0397435 | 01 | WI | AMC CLIA | OTHER | 52D0397878 | 01 | WI | TCMC CLIA | OTHER |