Provider Demographics
NPI:1619205390
Name:DAVID RESEN PATHOLOGY SERVICES S C
Entity Type:Organization
Organization Name:DAVID RESEN PATHOLOGY SERVICES S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-376-1255
Mailing Address - Street 1:8619 EDGEWATER RDG
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-9760
Mailing Address - Country:US
Mailing Address - Phone:920-376-1255
Mailing Address - Fax:
Practice Address - Street 1:8619 EDGEWATER RDG
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963-9760
Practice Address - Country:US
Practice Address - Phone:920-376-1255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32951207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33321900Medicaid
WI33321900Medicaid
000026051Medicare PIN