Provider Demographics
NPI:1487198511
Name:WESTSIDE PODIATRY GROUP LLC
Entity Type:Organization
Organization Name:WESTSIDE PODIATRY GROUP LLC
Other - Org Name:WESTSIDE PODIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:TELLEM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:585-225-9452
Mailing Address - Street 1:919 WESTFALL RD
Mailing Address - Street 2:BLUIDING C SUITE 130
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2638
Mailing Address - Country:US
Mailing Address - Phone:585-506-9790
Mailing Address - Fax:585-697-0116
Practice Address - Street 1:919 WESTFALL RD
Practice Address - Street 2:BLUIDING C SUITE 130
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2638
Practice Address - Country:US
Practice Address - Phone:585-506-9790
Practice Address - Fax:585-697-0116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04203316Medicaid
NY16336AMedicare PIN
NY04203316Medicaid