Provider Demographics
NPI:1891373593
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:
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 1:6520 W LAYTON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4500
Mailing Address - Country:US
Mailing Address - Phone:414-897-8380
Mailing Address - Fax:414-210-3489
Practice Address - Street 1:3900 W BROWN DEER RD STE 140
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209-1220
Practice Address - Country:US
Practice Address - Phone:414-897-8380
Practice Address - Fax:414-210-3489
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES ORTHOTICS & MEDICAL SUPPLY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies