Healthcare Provider Details

I. General information

NPI: 1578998696
Provider Name (Legal Business Name): LAKESHORE SURGICAL PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 ERIE CANAL DR SUITE E
ROCHESTER NY
14626-4604
US

IV. Provider business mailing address

1 PARK AVE
BROCKPORT NY
14420-1913
US

V. Phone/Fax

Practice location:
  • Phone: 585-637-2930
  • Fax: 585-637-2930
Mailing address:
  • Phone: 585-637-2930
  • Fax: 585-507-4707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number239232
License Number StateNY

VIII. Authorized Official

Name: DR. RICHARD J KING
Title or Position: PHYSICIAN
Credential: MD
Phone: 585-637-2930