Provider Demographics
NPI:1689695934
Name:GREAT LAKES PATHOLOGISTS SC
Entity Type:Organization
Organization Name:GREAT LAKES PATHOLOGISTS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-328-7950
Mailing Address - Street 1:8901 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2409
Mailing Address - Country:US
Mailing Address - Phone:414-328-7950
Mailing Address - Fax:414-328-7998
Practice Address - Street 1:8901 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2409
Practice Address - Country:US
Practice Address - Phone:414-328-7950
Practice Address - Fax:414-328-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32824300Medicaid
WICI2426OtherRAIL ROAD MEDICARE
WICI2426OtherRAIL ROAD MEDICARE
WI000052510Medicare PIN
WI000007045Medicare PIN
WI000065190Medicare PIN
WI000002045Medicare PIN
WI000060240Medicare PIN