Provider Demographics
NPI:1194821892
Name:WEST SIDE INTERNAL MEDICINE INC
Entity type:Organization
Organization Name:WEST SIDE INTERNAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILBUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-779-5505
Mailing Address - Street 1:PO BOX 451225
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-0631
Mailing Address - Country:US
Mailing Address - Phone:440-808-3700
Mailing Address - Fax:440-808-3675
Practice Address - Street 1:24700 LORAIN RD
Practice Address - Street 2:SUITE 207
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-2088
Practice Address - Country:US
Practice Address - Phone:440-779-5505
Practice Address - Fax:440-779-1342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2239661Medicaid
OH2239661Medicaid