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General NPI Number Information
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NPI Number | 1720218647
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Entity Type | Organization
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Legal Business Name | GREAT LAKES ANESTHESIA AND PAIN SPECIALISTS SC
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Dates
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Enumeration Date | 07/27/2009
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Last Update Date | 02/19/2025
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Provider Practice Location Address
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Address Line | 10101 S 27TH ST
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City | FRANKLIN
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State | WI
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Zip | 53132-7209
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Country | US
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Telephone | 414-817-5800
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 88829
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City | MILWAUKEE
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State | WI
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Zip | 53288-8829
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICER AND AUTHORIZED OFFICIAL
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Name | JENNIFER BOYD BALDOCK
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Credential |
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Telephone | 615-234-5954
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State | WI
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