Provider Demographics
NPI:1083710743
Name:MOUNTAINSIDE HEALTHCARE
Entity Type:Organization
Organization Name:MOUNTAINSIDE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:H
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:716-699-2588
Mailing Address - Street 1:39 MILL ST
Mailing Address - Street 2:
Mailing Address - City:ELLICOTTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14731-9702
Mailing Address - Country:US
Mailing Address - Phone:716-699-2588
Mailing Address - Fax:716-699-2618
Practice Address - Street 1:39 MILL ST
Practice Address - Street 2:
Practice Address - City:ELLICOTTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14731-9702
Practice Address - Country:US
Practice Address - Phone:716-699-2588
Practice Address - Fax:716-699-2618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty