Provider Demographics
| NPI: | 1932129434 |
|---|---|
| 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: | DR |
| 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: | 818-552-6230 |
| Mailing Address - Fax: | 818-242-8761 |
| Practice Address - Street 1: | 777 FLOWER ST STE A |
| Practice Address - Street 2: | |
| Practice Address - City: | GLENDALE |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 91201-3000 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 818-637-2000 |
| Practice Address - Fax: | 818-242-8761 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-07-20 |
| Last Update Date: | 2009-05-11 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 207N00000X, 207Q00000X, 207R00000X, 207RC0000X, 207RE0101X, 207RG0100X, 207RR0500X, 208000000X, 2085B0100X, 208800000X, 208D00000X, 208M00000X, 363A00000X, 363L00000X | ||
| CA | 363L00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
| No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
| No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2085B0100X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | Group - Multi-Specialty |
| No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
| No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CA | GR0068380 | Medicaid | |
| CA | GR0068383 | Medicaid | |
| CA | GR0068384 | Medicaid | |
| CA | GR0068381 | Medicaid | |
| CA | GR0068386 | Medicaid | |
| CA | GR0068387 | Medicaid | |
| CA | GR006838B | Medicaid | |
| CA | GR0068382 | Medicaid | |
| CA | GR0068385 | Medicaid | |
| CA | GR0068388 | Medicaid | |
| CA | GR006838A | Medicaid | |
| CA | W12279A | Medicare PIN | |
| CA | W12279D | Medicare PIN | |
| CA | W12279C | Medicare PIN | |
| CA | GR0068381 | Medicaid | |
| CA | GR0068380 | Medicaid | |
| CA | GR006838B | Medicaid | |
| CA | GR0068382 | Medicaid |
