Provider Demographics
NPI:1740516236
Name:LAKESIDE MEDICAL ASSOICATES, A MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:LAKESIDE MEDICAL ASSOICATES, A MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
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 1:1135 S SUNSET AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3937
Practice Address - Country:US
Practice Address - Phone:626-856-2215
Practice Address - Fax:626-960-2125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty