Healthcare Provider Details

I. General information

NPI: 1720218647
Provider Name (Legal Business Name): GREAT LAKES ANESTHESIA AND PAIN SPECIALISTS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 S 27TH ST
FRANKLIN WI
53132-7209
US

IV. Provider business mailing address

PO BOX 88829
MILWAUKEE WI
53288-8829
US

V. Phone/Fax

Practice location:
  • Phone: 414-817-5800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateWI

VIII. Authorized Official

Name: JENNIFER BOYD BALDOCK
Title or Position: OFFICER AND AUTHORIZED OFFICIAL
Credential:
Phone: 615-234-5954