Provider Demographics
NPI:1962555854
Name:LAKESIDE HOSPITAL INTERNAL MEDICINE GROUP
Entity type:Organization
Organization Name:LAKESIDE HOSPITAL INTERNAL MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-637-9196
Mailing Address - Street 1:156 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1229
Mailing Address - Country:US
Mailing Address - Phone:585-395-6095
Mailing Address - Fax:585-395-6036
Practice Address - Street 1:156 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1229
Practice Address - Country:US
Practice Address - Phone:585-395-6095
Practice Address - Fax:585-395-6036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG0181141590OtherBLUE CROSS
NY02198570Medicaid
NYMG150OtherPREFERRED CARE
NY02198570Medicaid