Provider Demographics
NPI:1740589399
Name:LAKESHORE MEDICAL CLINIC LTD
Entity Type:Organization
Organization Name:LAKESHORE MEDICAL CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MASOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:WASIULLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-744-6589
Mailing Address - Street 1:5250 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-1321
Mailing Address - Country:US
Mailing Address - Phone:414-525-2433
Mailing Address - Fax:414-525-2421
Practice Address - Street 1:5250 S 108TH ST
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-1321
Practice Address - Country:US
Practice Address - Phone:414-525-2433
Practice Address - Fax:414-525-2421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care