Basic Information
| Provider Information | |||||||||
| NPI: | 1962555854 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESIDE HOSPITAL INTERNAL MEDICINE GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| 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: | 01/22/2007 | ||||||||
| LastUpdateDate: | 07/14/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEHTA | ||||||||
| AuthorizedOfficialFirstName: | RAJENDRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5856379196 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | G0181141590 | 01 | NY | BLUE CROSS | OTHER | 02198570 | 05 | NY | MEDICAID | MG150 | 01 | NY | PREFERRED CARE | OTHER |