Great Lakes Dermatology

Primary specialty

Procedural Dermatology PhysicianTaxonomy code 207NS0135X

Legal business name

GREAT LAKES DERMATOLOGY

Practice address

1515 S Greenbay Rd
Racine, WI 53406-4409

Phone

(262) 632-2074

Fax

(262) 632-2656

NPI assigned

Oct 23, 2006

Organization subpart

No

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

Authorized official

Name

Ms. Cathy J Dean

Title

Administrator

Phone

(800) 485-8640

Specialties & licenses 1

Addresses

Tax ID family

Great Lakes Dermatology3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

• Great Lakes Dermatology

  • Procedural Dermatology Physician
  • Pleasant Prairie, WI
  • NPI 1205041688
  NPD tax ID
• Great Lakes Dermatology

  • Procedural Dermatology Physician
  • Kenosha, WI
  • NPI 1558576322
  NPD tax ID

Locations

Practitioners 1

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

• Kirsten J Antonneau, PAC

  • Physician Assistant
  • Mount Pleasant, WI
  • NPI 1467526400
  NPD (past)

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

{
    "created_epoch": "1161561600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1689757569",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1515 S GREENBAY RD",
            "city": "RACINE",
            "state": "WI",
            "postal_code": "534064409",
            "telephone_number": "262-632-2074",
            "fax_number": "262-632-2656"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1515 S GREENBAY RD",
            "city": "RACINE",
            "state": "WI",
            "postal_code": "534064409",
            "telephone_number": "262-632-2074",
            "fax_number": "262-632-2656"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES DERMATOLOGY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-23",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "DEAN",
        "authorized_official_first_name": "CATHY",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "800-485-8640",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "207NS0135X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology, Procedural Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Margaret Grady, OTR/L
• Stefanie M Graham, HYGIENIST
• Kimberly L Granger, RNC MSN FNP
• Shakee'US Graves, APSW
• Misty Jean Gray, SAC
• Great Lakes Neurosurgical Associates LLC
• Geraldine Green, APSW
• Nyisha O Green, CNA, CMA
• Michelle Greenlee
• Gregory T Isermann DDS Ms SC

• Procedural Dermatology Physician in Racine, WI
• Providers in Racine, WI by specialty
• Procedural Dermatology Physician in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.