Provider Demographics
NPI:1285839662
Name:LAKESHORE MEDICAL
Entity Type:Organization
Organization Name:LAKESHORE MEDICAL
Other - Org Name:
Other - Org Type:
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 AVENUE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172
Mailing Address - Country:US
Mailing Address - Phone:414-427-3280
Mailing Address - Fax:
Practice Address - Street 1:9200 W LOOMIS RD
Practice Address - Street 2:STE 208
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8887
Practice Address - Country:US
Practice Address - Phone:414-427-3280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0458040006Medicare ID - Type Unspecified