Basic Information
| Provider Information | |||||||||
| NPI: | 1083939722 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE AT LAKESIDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 156 WEST AVENUE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853956095 | ||||||||
| FaxNumber: | 5853956084 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144201229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853956095 | ||||||||
| FaxNumber: | 5853956084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2010 | ||||||||
| LastUpdateDate: | 04/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 5853956095 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKESIDE MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.