Provider Demographics
NPI:1962607366
Name:LAKESHORE MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:LAKESHORE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BANIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-766-9094
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:PAYOR ACTIVATION
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:
Practice Address - Street 1:14555 W NATIONAL AVE
Practice Address - Street 2:STE 165
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4494
Practice Address - Country:US
Practice Address - Phone:262-827-2959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0458040015Medicare ID - Type Unspecified