Provider Demographics
NPI:1093900136
Name:GREAT LAKES FAMILY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAWAID
Authorized Official - Middle Name:
Authorized Official - Last Name:QUDDUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:262-764-4390
Mailing Address - Street 1:6123 GREEN BAY ROAD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2927
Mailing Address - Country:US
Mailing Address - Phone:262-764-4390
Mailing Address - Fax:262-764-4396
Practice Address - Street 1:6123 GREEN BAY RD
Practice Address - Street 2:SUITE 120
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-764-4390
Practice Address - Fax:262-764-4396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45606020261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34414100Medicaid
WIH91649Medicare UPIN
WI000032057Medicare PIN