Provider Demographics
NPI:1114966892
Name:WATERTOWN PATHOLOGY PC
Entity Type:Organization
Organization Name:WATERTOWN PATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:WEGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-882-7749
Mailing Address - Street 1:PO BOX 875
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201
Mailing Address - Country:US
Mailing Address - Phone:605-882-7000
Mailing Address - Fax:605-882-5759
Practice Address - Street 1:401 9TH AVE NW
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201
Practice Address - Country:US
Practice Address - Phone:605-882-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD=========Medicaid
SD=========Medicaid