Organization
GREAT LAKES PATHOLOGISTS SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JIMMY R CLARK M.D. (PRESIDENT)
(414) 328-7950
Entity
Organization
Contact information
Practice address
8901 W LINCOLN AVE, WEST ALLIS, WI 53227-2409
(414) 328-7950
(414) 328-7998
Mailing address
8901 W LINCOLN AVE, WEST ALLIS, WI 53227-2409
(414) 328-7950
(414) 328-7998
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
32824300
—
WI
01
—
CI2426
RAIL ROAD MEDICARE
WI
Enumeration date
07/22/2006
Last updated
07/12/2010
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