Provider Demographics
NPI:1114087053
Name:LAKESHORE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:LAKESHORE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-299-1645
Mailing Address - Street 1:3611 S CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-3708
Mailing Address - Country:US
Mailing Address - Phone:414-762-7270
Mailing Address - Fax:414-762-7864
Practice Address - Street 1:3611 S CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-3708
Practice Address - Country:US
Practice Address - Phone:414-762-7270
Practice Address - Fax:414-762-7864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0458040012Medicare NSC