Provider Demographics
NPI:1629518006
Name:GREAT LAKES SURGERY LLC
Entity Type:Organization
Organization Name:GREAT LAKES SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
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:262-657-0224
Mailing Address - Street 1:6123 GREEN BAY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2927
Mailing Address - Country:US
Mailing Address - Phone:262-657-0224
Mailing Address - Fax:
Practice Address - Street 1:6123 GREEN BAY RD STE 101
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-657-0224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical