=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639136153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKESIDE MEMORIAL HOSPITAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2006
-----------------------------------------------------
Last Update Date | 08/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 156 WEST AVE
-----------------------------------------------------
City | BROCKPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14420-1229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-395-6095
-----------------------------------------------------
Fax | 585-395-6036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 156 WEST AVE
-----------------------------------------------------
City | BROCKPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14420-1229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-395-6095
-----------------------------------------------------
Fax | 585-395-6036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MICHAEL STAPLETON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 585-395-6095
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------