Basic Information
Provider Information | |||||||||
NPI: | 1003861188 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKESHORE MEDICAL CLINIC, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 15TH AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 531721160 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4147643241 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2000 E LAYTON AVE | ||||||||
Address2: | STE 100 | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532356053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4147446589 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2006 | ||||||||
LastUpdateDate: | 09/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HANSON | ||||||||
AuthorizedOfficialFirstName: | GAIL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
AuthorizedOfficialTelephone: | 4142991623 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 32797200 | 05 | WI |   | MEDICAID |