Provider Demographics
NPI:1932308186
Name:GREAT LAKES MEDICAL & SURGICAL CENTER
Entity Type:Organization
Organization Name:GREAT LAKES MEDICAL & SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NAMDARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-282-7575
Mailing Address - Street 1:PO BOX 210464
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221
Mailing Address - Country:US
Mailing Address - Phone:414-282-7575
Mailing Address - Fax:
Practice Address - Street 1:6000 SOUTH 27TH STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221
Practice Address - Country:US
Practice Address - Phone:414-282-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19858020208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty