Provider Demographics
NPI:1891707873
Name:LAKESIDE OB/GYN, S.C.
Entity Type:Organization
Organization Name:LAKESIDE OB/GYN, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:TREBIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-271-1116
Mailing Address - Street 1:2524 E WEBSTER PLACE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4518
Mailing Address - Country:US
Mailing Address - Phone:414-271-1116
Mailing Address - Fax:
Practice Address - Street 1:2524 E WEBSTER PL
Practice Address - Street 2:SUITE 303
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4246
Practice Address - Country:US
Practice Address - Phone:414-271-1116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33771-020207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty