Provider Demographics
NPI:1689256539
Name:LAKESHORE PAIN AND SPINE CENTER LLC
Entity Type:Organization
Organization Name:LAKESHORE PAIN AND SPINE CENTER LLC
Other - Org Name:LAKESHORE PAIN AND SPINE CENTER LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-484-4035
Mailing Address - Street 1:7201 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7201 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3532
Practice Address - Country:US
Practice Address - Phone:312-519-9936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty