Provider Demographics
NPI:1982834271
Name:LAKESHORE ORTHOPEDIC GROUP P.C.
Entity Type:Organization
Organization Name:LAKESHORE ORTHOPEDIC GROUP P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CONANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-366-7150
Mailing Address - Street 1:849 RTS 5 & 20
Mailing Address - Street 2:SUITE 1
Mailing Address - City:IRVING
Mailing Address - State:NY
Mailing Address - Zip Code:14081
Mailing Address - Country:US
Mailing Address - Phone:716-934-3493
Mailing Address - Fax:
Practice Address - Street 1:849 RTS 5 & 20
Practice Address - Street 2:SUITE 1
Practice Address - City:IRVING
Practice Address - State:NY
Practice Address - Zip Code:14081
Practice Address - Country:US
Practice Address - Phone:716-934-3493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY34634AMedicare UPIN
NY53007AMedicare UPIN
0253660001Medicare NSC