Provider Demographics
NPI:1649401258
Name:GREAT LAKES PAIN SPECIALISTS, LLC
Entity Type:Organization
Organization Name:GREAT LAKES PAIN SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:STAACKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-787-4026
Mailing Address - Street 1:225 S EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4257
Mailing Address - Country:US
Mailing Address - Phone:262-787-4026
Mailing Address - Fax:
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:414-761-1802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty