Great Lakes Foot & Ankle Centers Inc

Primary specialty

Foot & Ankle Surgery PodiatristTaxonomy code 213ES0103X

License

025 Issued in WI

Legal business name

GREAT LAKES FOOT & ANKLE CENTERS INC

Practice address

6123 Green Bay Rd
Suite 100
Kenosha, WI 53142-2927

Phone

(262) 652-3668

Fax

(262) 652-0564

NPI assigned

May 15, 2007

Organization subpart

No

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

Authorized official

Name

John L Bostanche, DPMNPI 1821092420

Title

Physician/Owner

Phone

(262) 652-3668

Specialties & licenses 2

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in WI2 enrollments

Enrollment records 2

Locations

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

• Patel Foot & Ankle LLC

  • Foot & Ankle Surgery Podiatrist
  • Kenosha, WI
  • NPI 1073241774
  NPPES parent name

Practitioners 1

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

• John L Bostanche, D.P.M.

  • Foot & Ankle Surgery Podiatrist
  • Kenosha, WI
  • NPI 1821092420
  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1179187200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632096000000",
    "number": "1295941409",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6123 GREEN BAY RD",
            "address_2": "SUITE 100",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531422927",
            "telephone_number": "262-652-3668",
            "fax_number": "262-652-0564"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6123 GREEN BAY RD",
            "address_2": "SUITE 100",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531422927",
            "telephone_number": "262-652-3668",
            "fax_number": "262-652-0564"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES FOOT & ANKLE CENTERS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-15",
        "last_updated": "2021-09-20",
        "certification_date": "2021-09-20",
        "status": "A",
        "authorized_official_last_name": "BOSTANCHE",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PHYSICIAN/OWNER",
        "authorized_official_telephone_number": "262-652-3668",
        "authorized_official_credential": "DPM"
    },
    "taxonomies": [
        {
            "code": "213ES0103X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": "IL",
            "license": "016",
            "primary": false
        },
        {
            "code": "213ES0103X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": "WI",
            "license": "025",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "43215000",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "43237400",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "43220100",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Brandy Michelle Graves
• Ebonie Gray, RN, APNP, FNP-BC
• Megan Gray, D.D.S.
• Great Lakes Dermatology
• Great Lakes Family Medical Center Inc
• Great Lakes Neurosurgical Associates LLC
• Great Lakes Surgery Center LLC
• Great Lakes Surgery LLC
• Green Bay Road Medical Services Inc
• Christine Green, PT, ATC

• Foot & Ankle Surgery Podiatrist in Kenosha, WI
• Providers in Kenosha, WI by specialty
• Foot & Ankle Surgery Podiatrist in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 20, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.