Provider Demographics
NPI:1609109925
Name:LAKESIDE MEMORIAL HOSPITAL INC.
Entity Type:Organization
Organization Name:LAKESIDE MEMORIAL HOSPITAL INC.
Other - Org Name:LAKESIDE EMERGENCY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STAPLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-395-6095
Mailing Address - Street 1:156 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1229
Mailing Address - Country:US
Mailing Address - Phone:585-395-6095
Mailing Address - Fax:585-395-6036
Practice Address - Street 1:156 WEST AVE
Practice Address - Street 2:
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:585-395-6036
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESIDE MEMORIAL HOSPITAL INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-18
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X
NY207PP0204X, 261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Multi-Specialty
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency CareGroup - Multi-Specialty