Provider Demographics
NPI:1770947897
Name:GREAT LAKES ORTHOTICS & MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:GREAT LAKES ORTHOTICS & MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SEAMUS
Authorized Official - Last Name:BUGGY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-828-9256
Mailing Address - Street 1:1670 MILLER PARK WAY
Mailing Address - Street 2:
Mailing Address - City:WEST MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3604
Mailing Address - Country:US
Mailing Address - Phone:414-897-8380
Mailing Address - Fax:262-436-1711
Practice Address - Street 1:1670 MILLER PARK WAY
Practice Address - Street 2:
Practice Address - City:WEST MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3604
Practice Address - Country:US
Practice Address - Phone:414-897-8380
Practice Address - Fax:262-436-1711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100063060Medicaid