Provider Demographics
NPI:1801849963
Name:LAKE COUNTRY PEDIATRICS SC
Entity Type:Organization
Organization Name:LAKE COUNTRY PEDIATRICS SC
Other - Org Name:LAKE COUNTRY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-569-7100
Mailing Address - Street 1:970 S SILVER LAKE ST
Mailing Address - Street 2:STE. 102
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3802
Mailing Address - Country:US
Mailing Address - Phone:262-569-7100
Mailing Address - Fax:262-567-6295
Practice Address - Street 1:970 S SILVER LAKE ST
Practice Address - Street 2:STE. 102
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3802
Practice Address - Country:US
Practice Address - Phone:262-569-7100
Practice Address - Fax:262-567-6295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35710208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21250600Medicaid