Provider Demographics
NPI:1487859815
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 STE A
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-3000
Mailing Address - Country:US
Mailing Address - Phone:818-637-2000
Mailing Address - Fax:818-242-8761
Practice Address - Street 1:25775 MCBEAN PKWY
Practice Address - Street 2:SUITE 107
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-3708
Practice Address - Country:US
Practice Address - Phone:661-259-9680
Practice Address - Fax:661-964-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-16
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068388Medicaid
CAW12279CMedicare PIN
CAW12279Medicare PIN