Basic Information
| Provider Information | |||||||||
| NPI: | 1942359989 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESIDE MEMORIAL HOSPITAL INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | LAKESIDE PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853956095 | ||||||||
| FaxNumber: | 5853956084 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853956095 | ||||||||
| FaxNumber: | 5853956084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KINGDOLLAR | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNTS RECEIVABLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5853956095 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.