Provider Demographics
NPI:1619052800
Name:FOND DU LAC PATHOLOGY CONSULTANTS
Entity Type:Organization
Organization Name:FOND DU LAC PATHOLOGY CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEDYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-926-5800
Mailing Address - Street 1:PO BOX 107
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54936-0107
Mailing Address - Country:US
Mailing Address - Phone:920-929-9300
Mailing Address - Fax:920-923-5260
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:ST AGNES HOSP, PATHOLOGY DEPT
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-5840
Practice Address - Fax:920-929-0647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICO1718OtherRR MEDICARE
WI31770700Medicaid
WICO1718OtherRR MEDICARE
WI31770700Medicaid