| Organization Name: | GREAT LAKES FAMILY MEDICAL CENTER INC |
| NPI Number: | 1093900136 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JAWAID QUDDUS (PRESIDENT) |
| Mailing Address: | 6123 Green Bay Rd Suite 120 Kenosha |
| State: | WI US |
| Postal Code: | 531422927 |
| Phone Number: | 2627644390 |
| Fax Number: | 2627644396 |
| NPI Enumeration Date: | 09/12/2007 |
| NPI Last Update Date: | 08/26/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261Q00000X |
| License Number: | 45606020 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A facility or distinct part of one used for the diagnosis and treatment of outpatients. "Clinic/Center" is irregularly defined, sometimes being limited to organizations serving specialized treatment requirements or distinct patient/client groups (e.g., radiology, poor, and public health). |