Basic Information
| Provider Information | |||||||||
| NPI: | 1306941752 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTSIDE HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146113634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5854363040 | ||||||||
| FaxNumber: | 5852956009 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852546480 | ||||||||
| FaxNumber: | 5852956009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 10/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | DONOHUE | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5854363040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 2701220R | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 00355353 | 05 | NY | MEDICAID | G0182661590 | 01 | NY | BLUE CHOICE OF ROCHESTER | OTHER |