Provider Demographics
NPI:1215307657
Name:LAKESIDE MEDICAL CARE PLLC
Entity type:Organization
Organization Name:LAKESIDE MEDICAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:SASSE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:716-549-4999
Mailing Address - Street 1:8746 ERIE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ANGOLA
Mailing Address - State:NY
Mailing Address - Zip Code:14006-9620
Mailing Address - Country:US
Mailing Address - Phone:716-549-4999
Mailing Address - Fax:716-549-4998
Practice Address - Street 1:8746 ERIE RD
Practice Address - Street 2:SUITE A
Practice Address - City:ANGOLA
Practice Address - State:NY
Practice Address - Zip Code:14006-9620
Practice Address - Country:US
Practice Address - Phone:716-549-4999
Practice Address - Fax:716-549-4998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-28
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266476-1261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4529111 TYPE 2Medicaid
NYH29526Medicare UPIN
NY4529111 TYPE 2Medicaid