Provider Demographics
NPI:1083724967
Name:WESTSIDE MEDICAL GROUP
Entity Type:Organization
Organization Name:WESTSIDE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:KRAUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-755-4577
Mailing Address - Street 1:714 CHASE PARKWAY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3939
Mailing Address - Country:US
Mailing Address - Phone:203-755-4577
Mailing Address - Fax:203-756-3628
Practice Address - Street 1:714 CHASE PARKWAY
Practice Address - Street 2:SUITE 6
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3939
Practice Address - Country:US
Practice Address - Phone:203-755-4577
Practice Address - Fax:203-756-3628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004085800Medicaid
50WESTSIDECT01OtherBCBS
CT004085800Medicaid