Healthcare Provider Details

I. General information

NPI: 1861444291
Provider Name (Legal Business Name): GREAT LAKES RADIATION ONCOLOGY,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19333 W NORTH AVE
BROOKFIELD WI
53045-4132
US

IV. Provider business mailing address

19333 W NORTH AVE
BROOKFIELD WI
53045-4132
US

V. Phone/Fax

Practice location:
  • Phone: 414-447-2221
  • Fax: 262-641-6880
Mailing address:
  • Phone: 414-447-2221
  • Fax: 262-641-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID M SHERMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 414-447-2221