Lake Country Endoscopy Center, LLC

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

Legal business name

LAKE COUNTRY ENDOSCOPY CENTER, LLC

Practice address

1185 Corporate Center Dr
Suite 125
Oconomowoc, WI 53066-4845

Phone

(414) 454-0600

Fax

(414) 454-0971

NPI assigned

Apr 8, 2008

Organization subpart

No

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

Authorized official

Name

Bao Xiong Thao

Title

Authorized Official

Phone

(414) 908-6506

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in WI

Enrollment records 1

Listed as

Lake Country Endoscopy Center LLCCCN 52C0001083

Medicare certification status

ActiveFrom the Provider of Services file

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• David A. Carron, MD

  • Gastroenterology Physician
  • Milwaukee, WI
  • NPI 1023085487
  NPD

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

{
    "created_epoch": "1207612800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1736294400000",
    "number": "1184897472",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2801 W KINNICKINNIC RIVER PKWY STE 1080",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532153689",
            "telephone_number": "414-908-6615",
            "fax_number": "414-908-6634"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1185 CORPORATE CENTER DR",
            "address_2": "SUITE 125",
            "city": "OCONOMOWOC",
            "state": "WI",
            "postal_code": "530664845",
            "telephone_number": "414-454-0600",
            "fax_number": "414-454-0971"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE COUNTRY ENDOSCOPY CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-08",
        "last_updated": "2025-01-08",
        "certification_date": "2025-01-08",
        "status": "A",
        "authorized_official_last_name": "XIONG THAO",
        "authorized_official_first_name": "BAO",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "414-908-6506"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1184897472",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Lake Area Free Clinic
• Lake Country Birth LLC
• Lake Country Classical Academy, Inc.
• Lake Country Dentistry, L.L.C.
• Lake Country Emergency Physicians
• Lake Country Pain Treatment
• Lake Country Pediatrics SC (Lake Country Physicians)
• Lake Country Pharmacy
• Lake Country Private Medical, S.C.
• Peter Mathew Lake, MD

• Ambulatory Surgical Clinic/Center in Oconomowoc, WI
• Providers in Oconomowoc, WI by specialty
• Ambulatory Surgical Clinic/Center in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.