Healthcare Provider Details

I. General information

NPI: 1609109925
Provider Name (Legal Business Name): LAKESIDE MEMORIAL HOSPITAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 WEST AVE
BROCKPORT NY
14420-1229
US

IV. Provider business mailing address

156 WEST AVE
BROCKPORT NY
14420-1229
US

V. Phone/Fax

Practice location:
  • Phone: 585-395-6095
  • Fax: 585-395-6036
Mailing address:
  • Phone: 585-395-6095
  • Fax: 585-395-6036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number
License Number StateNY

VIII. Authorized Official

Name: MICHAEL STAPLETON
Title or Position: CEO
Credential:
Phone: 585-395-6095