Provider Demographics
NPI:1578998696
Name:LAKESHORE SURGICAL PRACTICE, PC
Entity Type:Organization
Organization Name:LAKESHORE SURGICAL PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-637-2930
Mailing Address - Street 1:1 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1913
Mailing Address - Country:US
Mailing Address - Phone:585-637-2930
Mailing Address - Fax:585-507-4707
Practice Address - Street 1:30 ERIE CANAL DR
Practice Address - Street 2:SUITE E
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4604
Practice Address - Country:US
Practice Address - Phone:585-637-2930
Practice Address - Fax:585-637-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2392322086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02752716Medicaid
NYJ300058709Medicare PIN
NY02752716Medicaid