Provider Demographics
NPI:1992135925
Name:LAKESHORE VEINS, S.C.
Entity type:Organization
Organization Name:LAKESHORE VEINS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BARTEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-787-4050
Mailing Address - Street 1:1361 W TOWNE SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5047
Mailing Address - Country:US
Mailing Address - Phone:262-241-3999
Mailing Address - Fax:262-241-8003
Practice Address - Street 1:1361 W TOWNE SQUARE RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5047
Practice Address - Country:US
Practice Address - Phone:262-787-4050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI382912085R0202X
WI45074208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32614400Medicaid