Basic Information
| Provider Information | |||||||||
| NPI: | 1184897472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE COUNTRY ENDOSCOPY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 W KINNICKINNIC RIVER PKWY STE 1080 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149086601 | ||||||||
| FaxNumber: | 4143852980 | ||||||||
| Practice Location | |||||||||
| Address1: | 1185 CORPORATE CENTER DR | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144540600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOLLOY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4144540600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1184897472 | 05 | WI | MEDICAID |