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General NPI Number Information
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NPI Number | 1174651046
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Entity Type | Organization
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Legal Business Name | CANALSIDE PRIMARY CARE PC
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 12/26/2019
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Provider Practice Location Address
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Address Line | 43 NIAGARA ST
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City | NORTH TONAWANDA
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State | NY
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Zip | 14120-6115
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Country | US
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Telephone | 716-690-2001
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Fax | 716-690-2239
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Provider Business Mailing Address
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Address Line | 908 NIAGARA FALLS BLVD STE 208
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City | NORTH TONAWANDA
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State | NY
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Zip | 14120-2019
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Country | US
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Telephone | 716-692-3302
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Fax | 716-692-4342
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Authorized Official
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Title or Position | OWNER
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Name | LYNNE SUSAN ROSS
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Credential | MD
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Telephone | 716-690-2001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 229399
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License Number State | NY
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