Provider Demographics
NPI:1336337187
Name:LAKESHORE MEDICAL CLINIC, LTD
Entity Type:Organization
Organization Name:LAKESHORE MEDICAL CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MASOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:WASIULLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-744-6589
Mailing Address - Street 1:4131 W LOOMIS RD
Mailing Address - Street 2:STE 110
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2057
Mailing Address - Country:US
Mailing Address - Phone:414-281-5153
Mailing Address - Fax:
Practice Address - Street 1:4131 W LOOMIS RD
Practice Address - Street 2:STE 110
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2057
Practice Address - Country:US
Practice Address - Phone:414-281-5153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0458040022Medicare NSC