Basic Information
| Provider Information | |||||||||
| NPI: | 1801173448 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESHORE SURGICAL PRACTICE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144201229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3159867882 | ||||||||
| FaxNumber: | 3159864768 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144201229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3159867882 | ||||||||
| FaxNumber: | 3159864768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2011 | ||||||||
| LastUpdateDate: | 11/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | PLATT | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3159867882 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.