1487198511 NPI number — WESTSIDE PODIATRY GROUP LLC

Table of content: (NPI 1487198511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487198511 NPI number — WESTSIDE PODIATRY GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTSIDE PODIATRY GROUP LLC
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:
Provider Other Organization Name Type Code:
6
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:
1487198511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
919 WESTFALL RD
Provider Second Line Business Mailing Address:
BLUIDING C SUITE 130
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14618-2638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-506-9790
Provider Business Mailing Address Fax Number:
585-697-0116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
919 WESTFALL RD
Provider Second Line Business Practice Location Address:
BLUIDING C SUITE 130
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14618-2638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-506-9790
Provider Business Practice Location Address Fax Number:
585-697-0116
Provider Enumeration Date:
12/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TELLEM
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
ERIC
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
585-225-9452

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , 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: 04203316 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com