Basic Information
| Provider Information | |||||||||
| NPI: | 1003904624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESIDE IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144201229 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144201229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168592954 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | SILBER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7168592954 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02852633 | 05 | NY | MEDICAID |