Provider Demographics
NPI:1639374937
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
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:414-744-6589
Mailing Address - Street 1:180 N MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6013
Mailing Address - Country:US
Mailing Address - Phone:414-227-1127
Mailing Address - Fax:
Practice Address - Street 1:180 N MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6013
Practice Address - Country:US
Practice Address - Phone:414-227-1127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
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
WI0458040018Medicare ID - Type Unspecified