Provider Demographics
NPI:1639136153
Name:LAKESIDE MEMORIAL HOSPITAL INC.
Entity Type:Organization
Organization Name:LAKESIDE MEMORIAL HOSPITAL INC.
Other - Org Name:
Other - Org Type:
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 282N00000X
NY261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY14005907OtherEXCELLUS - OUTPATIENT
NY100003CFOtherPREFERRED CARE
NY106418AZOtherPREFERRED CARE-PHYS & MID
NY70000AOtherMEDICARE-PHYS & MID PRACT
NY02198570OtherMEDICAID-PHYS & MID PRACT
NY14005907OtherEXCELLUS-PHYS & MID PRACT
NY00279543Medicaid
NY12005907OtherEXCELLUS - INPATIENT
NY00279543Medicaid