Provider Demographics
NPI:1295941409
Name:GREAT LAKES FOOT & ANKLE CENTERS INC
Entity type:Organization
Organization Name:GREAT LAKES FOOT & ANKLE CENTERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOSTANCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-652-3668
Mailing Address - Street 1:6123 GREEN BAY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2927
Mailing Address - Country:US
Mailing Address - Phone:262-652-3668
Mailing Address - Fax:262-652-0564
Practice Address - Street 1:6123 GREEN BAY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-652-3668
Practice Address - Fax:262-652-0564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016213ES0103X
WI025213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43215000Medicaid
WI43237400Medicaid
WI43220100Medicaid
U33618Medicare UPIN
WI000081059Medicare ID - Type Unspecified
WI000081059Medicare ID - Type UnspecifiedGROUP
WI43215000Medicaid
V01175Medicare UPIN
WI1001630001Medicare NSC
IL999210Medicare ID - Type Unspecified
IL452880Medicare ID - Type Unspecified
U18653Medicare UPIN