Provider Demographics
NPI:1518720291
Name:LAKESIDE MEDICAL PRACTICE PLLC
Entity type:Organization
Organization Name:LAKESIDE MEDICAL PRACTICE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:716-526-1183
Mailing Address - Street 1:133 E. FAIRMOUNT AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1948
Mailing Address - Country:US
Mailing Address - Phone:716-526-1183
Mailing Address - Fax:716-526-1165
Practice Address - Street 1:133 FAIRMOUNT AVENUE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750-1948
Practice Address - Country:US
Practice Address - Phone:716-526-1183
Practice Address - Fax:716-526-1165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-05
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center