Provider Demographics
NPI:1023146354
Name:WESTSIDE FAMILY MEDICINE
Entity type:Organization
Organization Name:WESTSIDE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROBAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-892-7518
Mailing Address - Street 1:1316 JACKIE RD SE STE 900
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6612
Mailing Address - Country:US
Mailing Address - Phone:505-892-7518
Mailing Address - Fax:505-892-9092
Practice Address - Street 1:1316 JACKIE RD SE STE 900
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6612
Practice Address - Country:US
Practice Address - Phone:505-892-7518
Practice Address - Fax:505-892-9092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-86207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA01635Medicare UPIN