LAKESHORE MEDICAL CLINIC, LLC – Family Medicine Physician, NPI 1003861188
Family Medicine Physician
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Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for LAKESHORE MEDICAL CLINIC, LLC
PO BOX 735044
CHICAGO, IL 606735044
Phone: (414) 647-6326
Type: Mailing
2000 E LAYTON AVE STE 100
SAINT FRANCIS, WI 532356054
Phone: (414) 744-6589
Type: Location
100, 15th Avenue, South Milwaukee, Milwaukee County, Wisconsin, 53172, United States
SOUTH MILWAUKEE, WI 531721160
Phone: (414) 764-3241
Type: Mailing
2000, East Layton Avenue, Saint Francis, Milwaukee County, Wisconsin, 53235, United States
STE 100
MILWAUKEE, WI 532356053
Phone: (414) 744-6589
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2024-04-18
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Past revalidation due date
Earliest CMS due date was 2024-09-30 (617 days ago).
Enrollment records
2
Earliest due date
2024-09-30
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| O20031110000224 | O | Physical/Occupational Therapy Group In Private Practice | WI | 2024-09-30 |
| O20240418001321 | O | In-Person Mdpp Supplier | WI | TBD |
What to do next
- Verify current status on the CMS Revalidation Lookup Tool immediately.
- Complete revalidation in PECOS or contact your Medicare Administrative Contractor (MAC).
- Overdue revalidation can lead to deactivation of Medicare billing privileges.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 60673)
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