NPIMap

Organization Active NPI

Great Lakes Family Medical Center Inc

  • Clinic/Center
  • Kenosha, WI
National Provider Identifier
1093900136
Registry record updated Aug 26, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
License
45606020 Issued in WI
Legal business name
GREAT LAKES FAMILY MEDICAL CENTER INC
Practice address
6123 Green Bay Rd
Suite 120
Kenosha, WI 53142-2927
Phone
(262) 764-4390
Fax
(262) 764-4396
NPI assigned
Sep 12, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 26, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jawaid Quddus, M.D., PH.D.
Title
President
Phone
(262) 764-4390

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 45606020 WI Primary

Addresses

Primary practice location

6123 Green Bay Rd
Suite 120
Kenosha, WI 53142-2927

Mailing address

6123 Green Bay Road
Suite 120
Kenosha, WI 53142-2927
Phone (262) 764-4390

Other identifiers 1

IdentifierTypeStateIssuer
34414100MedicaidWI

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1189555200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1282780800000",
    "number": "1093900136",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6123 GREEN BAY ROAD",
            "address_2": "SUITE 120",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531422927",
            "telephone_number": "262-764-4390",
            "fax_number": "262-764-4396"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6123 GREEN BAY RD",
            "address_2": "SUITE 120",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531422927",
            "telephone_number": "262-764-4390",
            "fax_number": "262-764-4396"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES FAMILY MEDICAL CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-09-12",
        "last_updated": "2010-08-26",
        "status": "A",
        "authorized_official_last_name": "QUDDUS",
        "authorized_official_first_name": "JAWAID",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "262-764-4390",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D., PH.D."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "WI",
            "license": "45606020",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "34414100",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kenosha, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 26, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.