MEDICARE: LAKESIDE MEMORIAL HOSPITAL INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	261QU0200X	Urgent Care Clinic/Center	NY
2	207P00000X	Emergency Medicine Physician
3	282N00000X	General Acute Care Hospital

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	70000A	OTHER	NY	MEDICARE-PHYS & MID PRACT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14005907	OTHER	NY	EXCELLUS - OUTPATIENT
2	100003CF	OTHER	NY	PREFERRED CARE
3	106418AZ	OTHER	NY	PREFERRED CARE-PHYS & MID
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	14005907	OTHER	NY	EXCELLUS-PHYS & MID PRACT
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	12005907	OTHER	NY	EXCELLUS - INPATIENT

General Provider Information

NPI Number	:	1639136153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE MEMORIAL HOSPITAL INC.

Provider Business Mailing Address
First Line	:	156 WEST AVE
Second Line	:
City	:	BROCKPORT
State	:	NY
Zip	:	14420-1229
Country	:	US
Telephone Number	:	585-395-6095
Fax Number	:	585-395-6036

Provider Business Practice Location Address
First Line	:	156 WEST AVE
Second Line	:
City	:	BROCKPORT
State	:	NY
Zip	:	14420-1229
Country	:	US
Telephone Number	:	585-395-6095
Fax Number	:	585-395-6036

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL STAPLETON
Credential	:
Telephone Number	:	585-395-6095

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	08/25/2009

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Directions to “LAKESIDE MEMORIAL HOSPITAL INC. ” Practice Location

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