Provider Demographics
NPI:1134317738
Name:GREAT LAKES NEUROSURGICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:GREAT LAKES NEUROSURGICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YASHIIP
Authorized Official - Middle Name:SINGH
Authorized Official - Last Name:PANNU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-385-8702
Mailing Address - Street 1:2901 W KINNICKINNIC RIVER PARKWAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215
Mailing Address - Country:US
Mailing Address - Phone:414-385-8702
Mailing Address - Fax:
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PARKWAY
Practice Address - Street 2:SUITE 300
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-385-8702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207T00000X
WI45579-20207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6265290001Medicare NSC