1487976544 NPI number — LAKESHORE MEDICAL CLINIC LTD

Table of content: (NPI 1487976544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487976544 NPI number — LAKESHORE MEDICAL CLINIC LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESHORE MEDICAL CLINIC LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LMC BUCYRUS MEDICAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487976544
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 MILWAUKEE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53172-2013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-768-4444
Provider Business Mailing Address Fax Number:
414-768-4782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53172-2013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-768-4444
Provider Business Practice Location Address Fax Number:
414-768-4782
Provider Enumeration Date:
02/17/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WASIULLAH
Authorized Official First Name:
MASOOD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-768-5430

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)