Provider Demographics
NPI:1730239583
Name:WESTSIDE MEDICAL CARE, INC
Entity type:Organization
Organization Name:WESTSIDE MEDICAL CARE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-792-1412
Mailing Address - Street 1:1810 59TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-4630
Mailing Address - Country:US
Mailing Address - Phone:941-792-1412
Mailing Address - Fax:941-795-0753
Practice Address - Street 1:1810 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4630
Practice Address - Country:US
Practice Address - Phone:941-792-1412
Practice Address - Fax:941-795-0753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24084174400000X
FLME71117174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBLUE CROSS BLUE SHIEOther94816
FLDE7241OtherRR MEDICARE
FLBLUE CROSS BLUE SHIEOther94816