Provider Demographics
NPI:1437118619
Name:WEST SIDE COMMUNITY HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:WEST SIDE COMMUNITY HEALTH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARITZA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-602-7561
Mailing Address - Street 1:153 CESAR CHAVEZ ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2226
Mailing Address - Country:US
Mailing Address - Phone:651-222-1816
Mailing Address - Fax:651-602-7517
Practice Address - Street 1:153 CESAR CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2226
Practice Address - Country:US
Practice Address - Phone:651-222-1816
Practice Address - Fax:651-602-7517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302133261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN29548WEOtherBCBS
MN104403OtherUCARE
MN109057OtherHEALTHPARTNERS
MN836253000Medicaid
MNC00143Medicare PIN
MN109057OtherHEALTHPARTNERS