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General NPI Number Information
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NPI Number | 1093900136
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Entity Type | Organization
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Legal Business Name | GREAT LAKES FAMILY MEDICAL CENTER INC
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Dates
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Enumeration Date | 09/12/2007
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Last Update Date | 08/26/2010
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Provider Practice Location Address
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Address Line | 6123 GREEN BAY RD SUITE 120
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City | KENOSHA
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State | WI
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Zip | 53142-2927
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Country | US
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Telephone | 262-764-4390
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Fax | 262-764-4396
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Provider Business Mailing Address
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Address Line | 6123 GREEN BAY ROAD SUITE 120
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City | KENOSHA
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State | WI
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Zip | 53142-2927
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Country | US
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Telephone | 262-764-4390
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Fax | 262-764-4396
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAWAID QUDDUS
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Credential | M.D., PH.D.
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Telephone | 262-764-4390
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 45606020
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License Number State | WI
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