Southern Lakes Endoscopy LLC

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

Legal business name

SOUTHERN LAKES ENDOSCOPY LLC

Practice address

240 Maple Ave Ste 2220
Mukwonago, WI 53149-8475

Phone

(414) 454-0600

Fax

(414) 454-0971

NPI assigned

Jul 3, 2018

Organization subpart

No

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

Authorized official

Name

Amy Jo Burns

Title

Director Revenue Cycle Management

Phone

(262) 970-7825

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in WI

Enrollment records 1

Listed as

Southern Lakes Endoscopy CenterCCN 52C0001122

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

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

{
    "created_epoch": "1530576000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1773878400000",
    "number": "1851887715",
    "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": "240 MAPLE AVE STE 2220",
            "city": "MUKWONAGO",
            "state": "WI",
            "postal_code": "531498475",
            "telephone_number": "414-454-0600",
            "fax_number": "414-454-0971"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN LAKES ENDOSCOPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-03",
        "last_updated": "2026-03-19",
        "certification_date": "2026-03-19",
        "status": "A",
        "authorized_official_last_name": "BURNS",
        "authorized_official_first_name": "AMY",
        "authorized_official_middle_name": "JO",
        "authorized_official_title_or_position": "DIRECTOR REVENUE CYCLE MANAGEMENT",
        "authorized_official_telephone_number": "262-970-7825"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Ambulatory Surgical Clinic/Center in Mukwonago, WI
• Providers in Mukwonago, 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 Mar 19, 2026; 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.