Provider Demographics
NPI:1982789210
Name:LAKE COUNTRY FOOT & ANKLE, S.C.
Entity type:Organization
Organization Name:LAKE COUNTRY FOOT & ANKLE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-695-6440
Mailing Address - Street 1:1177 QUAIL CT STE 103
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3768
Mailing Address - Country:US
Mailing Address - Phone:262-695-6440
Mailing Address - Fax:262-695-2668
Practice Address - Street 1:1177 QUAIL CT STE 103
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3768
Practice Address - Country:US
Practice Address - Phone:262-695-6440
Practice Address - Fax:262-695-2668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI794025213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU83709Medicare UPIN
WI000082018Medicare ID - Type Unspecified
WI4936830001Medicare NSC