Provider Demographics
NPI:1558576322
Name:GREAT LAKES DERMATOLOGY
Entity Type:Organization
Organization Name:GREAT LAKES DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-485-8640
Mailing Address - Street 1:3610 30TH AVENUE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 30TH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1695
Practice Address - Country:US
Practice Address - Phone:262-658-2594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty