MEDICARE: GREAT LAKES DERMATOLOGY SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851467047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES DERMATOLOGY SC

Provider Business Mailing Address
First Line	:	6233 BANKERS RD STE 3
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53403-9700
Country	:	US
Telephone Number	:	262-898-4400
Fax Number	:	262-898-4423

Provider Business Practice Location Address
First Line	:	6233 BANKERS RD
Second Line	:	SUITE 3
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53403-9700
Country	:	US
Telephone Number	:	262-898-4400
Fax Number	:	262-898-4423

Authorized Official
Title or Position	:	MANAGER OF COMPLIANCE
Name	:	KRISTY K OLSON
Credential	:
Telephone Number	:	262-989-4400

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	05/26/2015

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