Provider Demographics
NPI:1174651046
Name:CANALSIDE PRIMARY CARE PC
Entity Type:Organization
Organization Name:CANALSIDE PRIMARY CARE PC
Other - Org Name:LYNNE ROSS MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-690-2001
Mailing Address - Street 1:908 NIAGARA FALLS BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:43 NIAGARA ST
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-6115
Practice Address - Country:US
Practice Address - Phone:716-690-2001
Practice Address - Fax:716-690-2239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02494544Medicaid