Basic Information
| Provider Information | |||||||||
| NPI: | 1205886918 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BUTTE DES MORTS PATHOLOGY, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 E WASHINGTON ST | ||||||||
| Address2: | P O BOX 8031 | ||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549115490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002368252 | ||||||||
| FaxNumber: | 9207390124 | ||||||||
| Practice Location | |||||||||
| Address1: | 1506 S ONEIDA ST | ||||||||
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| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549151305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207382000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PODLUSKY | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9207382000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 32881300 | 05 | WI | MEDICAID |