Provider Demographics
NPI:1013609213
Name:GMG-13 LLC
Entity Type:Organization
Organization Name:GMG-13 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GAYLORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-946-2505
Mailing Address - Street 1:1707 N PROSPECT AVE UNIT 12A
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1912
Mailing Address - Country:US
Mailing Address - Phone:920-946-2505
Mailing Address - Fax:
Practice Address - Street 1:1707 N PROSPECT AVE UNIT 12A
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-1912
Practice Address - Country:US
Practice Address - Phone:920-946-2505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty