Healthcare Provider Details

I. General information

NPI: 1932308186
Provider Name (Legal Business Name): GREAT LAKES MEDICAL & SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 SOUTH 27TH STREET
MILWAUKEE WI
53221
US

IV. Provider business mailing address

PO BOX 210464
MILWAUKEE WI
53221
US

V. Phone/Fax

Practice location:
  • Phone: 414-282-7575
  • Fax:
Mailing address:
  • Phone: 414-282-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number19858020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number19858020
License Number StateWI

VIII. Authorized Official

Name: DR. BAHRAM NAMDARI
Title or Position: OWNER
Credential: MD
Phone: 414-282-7575