Provider Demographics
NPI:1578743019
Name:GREAT LAKES NEUROSURGICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:GREAT LAKES NEUROSURGICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YASHDIP
Authorized Official - Middle Name:S
Authorized Official - Last Name:PANNU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-385-8702
Mailing Address - Street 1:PO BOX 241393
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-9032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7884
Practice Address - Country:US
Practice Address - Phone:262-948-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES NEUROSURGICAL ASSOCIATES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-13
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000052140Medicare PIN