Provider Demographics
NPI:1700045168
Name:GREAT LAKES SURGERY CENTER LLC
Entity Type:Organization
Organization Name:GREAT LAKES SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:K
Authorized Official - Last Name:THIERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-657-3668
Mailing Address - Street 1:PO BOX 580772
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-8101
Mailing Address - Country:US
Mailing Address - Phone:262-657-3668
Mailing Address - Fax:
Practice Address - Street 1:6123 GREEN BAY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-657-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIPENDING261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical