Provider Demographics
NPI:1629206230
Name:LAKESHORE MEDICAL CLINIC
Entity type:Organization
Organization Name:LAKESHORE MEDICAL CLINIC
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:262-241-8000
Mailing Address - Street 1:100 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1160
Mailing Address - Country:US
Mailing Address - Phone:414-768-5430
Mailing Address - Fax:
Practice Address - Street 1:10520 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5537
Practice Address - Country:US
Practice Address - Phone:262-241-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies