Basic Information
| Provider Information | |||||||||
| NPI: | 1194821892 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST SIDE INTERNAL MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 451225 | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441450631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408083700 | ||||||||
| FaxNumber: | 4408083675 | ||||||||
| Practice Location | |||||||||
| Address1: | 24700 LORAIN RD | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440702088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407795505 | ||||||||
| FaxNumber: | 4407791342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILBUR | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4407795505 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2239661 | 05 | OH | MEDICAID |