Basic Information
| Provider Information | |||||||||
| NPI: | 1639136153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESIDE MEMORIAL HOSPITAL INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144201229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853956095 | ||||||||
| FaxNumber: | 5853956036 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144201229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853956095 | ||||||||
| FaxNumber: | 5853956036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 08/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | STAPLETON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5853956095 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | NY | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 14005907 | 01 | NY | EXCELLUS - OUTPATIENT | OTHER | 100003CF | 01 | NY | PREFERRED CARE | OTHER | 106418AZ | 01 | NY | PREFERRED CARE-PHYS & MID | OTHER | 70000A | 01 | NY | MEDICARE-PHYS & MID PRACT | OTHER | 02198570 | 01 | NY | MEDICAID-PHYS & MID PRACT | OTHER | 14005907 | 01 | NY | EXCELLUS-PHYS & MID PRACT | OTHER | 00279543 | 05 | NY | MEDICAID | 12005907 | 01 | NY | EXCELLUS - INPATIENT | OTHER |