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General NPI Number Information
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NPI Number | 1932308186
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Entity Type | Organization
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Legal Business Name | GREAT LAKES MEDICAL & SURGICAL CENTER
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Dates
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Enumeration Date | 07/17/2007
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Last Update Date | 07/17/2007
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Provider Practice Location Address
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Address Line | 6000 SOUTH 27TH STREET
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City | MILWAUKEE
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State | WI
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Zip | 53221
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Country | US
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Telephone | 414-282-7575
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 210464
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City | MILWAUKEE
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State | WI
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Zip | 53221
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Country | US
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Telephone | 414-282-7575
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BAHRAM NAMDARI
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Credential | MD
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Telephone | 414-282-7575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 19858020
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 19858020
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License Number State | WI
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