Provider Demographics
NPI:1740459072
Name:HART ROAD PATHOLOGY SC
Entity type:Organization
Organization Name:HART ROAD PATHOLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER PATIENT ACCOUNTS
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:JB
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-364-5123
Mailing Address - Street 1:1969 W HART RD
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2230
Mailing Address - Country:US
Mailing Address - Phone:608-364-5123
Mailing Address - Fax:
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2230
Practice Address - Country:US
Practice Address - Phone:608-364-5123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46411207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI54325Medicare PIN