Provider Demographics
NPI:1659317634
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 1:24355 LYONS AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91321-2300
Practice Address - Country:US
Practice Address - Phone:661-222-9381
Practice Address - Fax:661-222-2264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X, 207Q00000X, 207R00000X, 208000000X
CA363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068381Medicaid
CAGR0068381Medicaid
CAW12279Medicare PIN