Provider Demographics
NPI:1497980759
Name:GREAT LAKES MEDICAL LLC
Entity Type:Organization
Organization Name:GREAT LAKES MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOSTANCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-657-3668
Mailing Address - Street 1:DEPARTMENT 7917
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122
Mailing Address - Country:US
Mailing Address - Phone:773-885-7696
Mailing Address - Fax:773-409-5710
Practice Address - Street 1:8153 S 27TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-7012
Practice Address - Country:US
Practice Address - Phone:773-885-7696
Practice Address - Fax:773-409-5710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES FOOT & ANKLE CENTERS OF GREATER MILWAUKEE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical