NPIMap

Organization Active NPI

Great Lakes Surgery LLC

  • Ambulatory Surgical Clinic/Center
  • Kenosha, WI
National Provider Identifier
1629518006
Registry record updated Mar 3, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
Legal business name
GREAT LAKES SURGERY LLC
Practice address
6123 Green Bay Rd Ste 101
Kenosha, WI 53142-2927
Phone
(262) 657-0224
NPI assigned
Mar 3, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 3, 2017

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

Authorized official

Name
John L Bostanche, DPM
Title
Director
Phone
(262) 657-0224

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ambulatory Surgical Clinic/Center 261QA1903X Primary

Addresses

Primary practice location

6123 Green Bay Rd Ste 101
Kenosha, WI 53142-2927

Mailing address

6123 Green Bay Rd
Suite 100
Kenosha, WI 53142-2927
Phone (262) 657-0224

National Provider Directory

National Provider Directory

Locations

6123 Green Bay Rd
Ste 101
Kenosha, WI 53142
Phone (262) 657-0224

NPI Registry JSON

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

{
    "created_epoch": "1488499200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1488499200000",
    "number": "1629518006",
    "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": "262-657-0224"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6123 GREEN BAY RD STE 101",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531422927",
            "telephone_number": "262-657-0224"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES SURGERY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-03-03",
        "last_updated": "2017-03-03",
        "status": "A",
        "authorized_official_last_name": "BOSTANCHE",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "262-657-0224",
        "authorized_official_credential": "DPM"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "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 Mar 3, 2017; 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.