Provider Demographics
NPI:1083939722
Name:INTERNAL MEDICINE AT LAKESIDE
Entity Type:Organization
Organization Name:INTERNAL MEDICINE AT LAKESIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRACTICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-395-6095
Mailing Address - Street 1:156 WEST AVENUE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420
Mailing Address - Country:US
Mailing Address - Phone:585-395-6095
Mailing Address - Fax:585-395-6084
Practice Address - Street 1:156 WEST AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1229
Practice Address - Country:US
Practice Address - Phone:585-395-6095
Practice Address - Fax:585-395-6084
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESIDE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty