Provider Demographics
NPI:1104001288
Name:LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.
Other - Org Name:LAKESIDE COMMUNITY HEALTHCARE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WEINER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-637-2000
Mailing Address - Street 1:777 FLOWER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-3015
Mailing Address - Country:US
Mailing Address - Phone:818-637-2000
Mailing Address - Fax:818-242-8761
Practice Address - Street 1:1500 S CENTRAL AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2530
Practice Address - Country:US
Practice Address - Phone:818-247-3708
Practice Address - Fax:818-547-3146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty