Provider Demographics
NPI:1689757569
Name:GREAT LAKES DERMATOLOGY
Entity Type:Organization
Organization Name:GREAT LAKES DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-485-8640
Mailing Address - Street 1:1515 S GREENBAY RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4409
Mailing Address - Country:US
Mailing Address - Phone:262-632-2074
Mailing Address - Fax:262-632-2656
Practice Address - Street 1:1515 S GREENBAY RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4409
Practice Address - Country:US
Practice Address - Phone:262-632-2074
Practice Address - Fax:262-632-2656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty