NPIMap

Organization Active NPI

Great Lakes Pathologists SC

  • Anatomic Pathology & Clinical Pathology Physician
  • West Allis, WI
National Provider Identifier
1689695934
Registry record updated Oct 17, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Anatomic Pathology & Clinical Pathology PhysicianTaxonomy code 207ZP0102X
Legal business name
GREAT LAKES PATHOLOGISTS SC
Practice address
8901 W Lincoln Ave
West Allis, WI 53227-2409
Phone
(414) 328-7950
Fax
(414) 328-7998
NPI assigned
Jul 22, 2006
Last updated
Oct 17, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 17, 2026

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

Authorized official

Name
Jimmy R Clark, M.D.NPI 1952335069
Title
President
Phone
(414) 328-7950

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Anatomic Pathology & Clinical Pathology Physician 207ZP0102X NU Primary

Addresses

Primary practice location

8901 W Lincoln Ave
West Allis, WI 53227-2409

Mailing address

8901 W Lincoln Ave
West Allis, WI 53227-2409
Phone (414) 328-7950

Other identifiers 2

IdentifierTypeStateIssuer
CI2426OtherWIRAIL ROAD MEDICARE
32824300MedicaidWI

Electronic endpoints 1

TypeEndpointUseAffiliation
FHIR URL https://cpiapigateway.cms.gov/api/esmdf/ext/v1/fhir/Practitioner/ Other Management Services Network, LLC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031112000106 WI Part B Supplier - Clinic/Group Practice 7315850682 Receives reassigned benefits from 65 practitioners
Practice locations: Two Rivers, WI; West Allis, WI; Waukesha, WI; Watertown, WI; Summit, WI; Sheboygan, WI; Oshkosh, WI; Oconomowoc, WI…

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 76

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 76

NPI Registry JSON

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

{
    "created_epoch": "1153526400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1792195200000",
    "number": "1689695934",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8901 W LINCOLN AVE",
            "city": "WEST ALLIS",
            "state": "WI",
            "postal_code": "532272409",
            "telephone_number": "414-328-7950",
            "fax_number": "414-328-7998"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8901 W LINCOLN AVE",
            "city": "WEST ALLIS",
            "state": "WI",
            "postal_code": "532272409",
            "telephone_number": "414-328-7950",
            "fax_number": "414-328-7998"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES PATHOLOGISTS SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-22",
        "last_updated": "2026-10-17",
        "certification_date": "2026-10-17",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "JIMMY",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "414-328-7950",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAIL ROAD MEDICARE",
            "identifier": "CI2426",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32824300",
            "state": "WI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://cpiapigateway.cms.gov/api/esmdf/ext/v1/fhir/Practitioner/",
            "affiliation": "Y",
            "endpointDescription": "urn:oid:2.16.840.1.113883.3.1036.1",
            "affiliationName": "Management Services Network, LLC",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "2357 Warm Springs RD Ste 400",
            "city": "Columbus",
            "state": "GA",
            "country_code": "US",
            "postal_code": "319046874",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in West Allis, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 17, 2026; 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.