Organization
GREAT LAKES FAMILY MEDICAL CENTER INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JAWAID QUDDUS M.D., PH.D. (PRESIDENT)
(262) 764-4390
Entity
Organization
Contact information
Practice address
6123 GREEN BAY RD, SUITE 120, KENOSHA, WI 53142-2927
(262) 764-4390
(262) 764-4396
Mailing address
6123 GREEN BAY ROAD, SUITE 120, KENOSHA, WI 53142-2927
(262) 764-4390
(262) 764-4396
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
45606020
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
34414100
—
WI
Enumeration date
09/12/2007
Last updated
08/26/2010
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