Provider Demographics
NPI:1790996056
Name:LAKESIDE HEALTH SYSTEM
Entity Type:Organization
Organization Name:LAKESIDE HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDE
Authorized Official - Phone:585-395-6044
Mailing Address - Street 1:156 WEST AVE
Mailing Address - Street 2:FAMILY WELLNESS CENTER
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1229
Mailing Address - Country:US
Mailing Address - Phone:585-395-6044
Mailing Address - Fax:
Practice Address - Street 1:1173 PECK RD
Practice Address - Street 2:
Practice Address - City:HILTON
Practice Address - State:NY
Practice Address - Zip Code:14468-9347
Practice Address - Country:US
Practice Address - Phone:585-366-4082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY838482261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ10077Medicare UPIN