Provider Demographics
NPI:1851467047
Name:GREAT LAKES DERMATOLOGY SC
Entity Type:Organization
Organization Name:GREAT LAKES DERMATOLOGY SC
Other - Org Name:ASCEND DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:K
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-989-4400
Mailing Address - Street 1:6233 BANKERS RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53403-9700
Mailing Address - Country:US
Mailing Address - Phone:262-898-4400
Mailing Address - Fax:262-898-4423
Practice Address - Street 1:6233 BANKERS RD
Practice Address - Street 2:SUITE 3
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53403-9700
Practice Address - Country:US
Practice Address - Phone:262-898-4400
Practice Address - Fax:262-898-4423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICH7592Medicaid
WICH7592Medicaid
WIWI1286Medicare PIN
WI32125Medicare PIN