1972522670 NPI number — LAKESIDE MEMORIAL HOSPITAL INC.

Table of content: (NPI 1972522670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972522670 NPI number — LAKESIDE MEMORIAL HOSPITAL INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE MEMORIAL HOSPITAL INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKESIDE OB/GYN
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972522670
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
156 WEST AVE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
BROCKPORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14420-1229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-637-6040
Provider Business Mailing Address Fax Number:
588-637-4737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
156 WEST AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
BROCKPORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14420-1229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-637-6040
Provider Business Practice Location Address Fax Number:
588-637-4737
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHARE
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL BILLER
Authorized Official Telephone Number:
585-637-6040

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  235519 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0712876 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7819729 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0027353001 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010235519 . This is a "BCBS ROCHESTER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00927965001 . This is a "WNY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02675890 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 170748CK . This is a "PREFFERED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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