Provider Demographics
NPI:1396822854
Name:LAKESHORE MEDICAL CLINIC, LTD.
Entity Type:Organization
Organization Name:LAKESHORE MEDICAL CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
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:414-764-3241
Mailing Address - Street 1:4131 W LOOMIS RD
Mailing Address - Street 2:STE 200
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2051
Mailing Address - Country:US
Mailing Address - Phone:414-281-5151
Mailing Address - Fax:
Practice Address - Street 1:4131 W LOOMIS RD
Practice Address - Street 2:STE 200
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2051
Practice Address - Country:US
Practice Address - Phone:414-281-5151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0458040019Medicare ID - Type Unspecified