Basic Information
Provider Information | |||||||||
NPI: | 1053748160 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKESHORE MEDICAL CLINIC | ||||||||
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: | 4147624225 | ||||||||
Practice Location | |||||||||
Address1: | 100 15TH AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 531721160 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4147643241 | ||||||||
FaxNumber: | 4147624225 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2013 | ||||||||
LastUpdateDate: | 10/03/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAVORA | ||||||||
AuthorizedOfficialFirstName: | FRANK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4147643241 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5513-33 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.