Provider Demographics
NPI:1174851893
Name:LAKESHORE MEDICAL CLINIC LTD
Entity Type:Organization
Organization Name:LAKESHORE MEDICAL CLINIC LTD
Other - Org Name:LMC BUCYRUS MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MASOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:WASIULLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-744-6589
Mailing Address - Street 1:100 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1160
Mailing Address - Country:US
Mailing Address - Phone:414-764-3241
Mailing Address - Fax:
Practice Address - Street 1:1100 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-2013
Practice Address - Country:US
Practice Address - Phone:414-764-4003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000002120Medicare PIN
WI0458040025Medicare NSC