Basic Information
| Provider Information | |||||||||
| NPI: | 1184884769 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESIDE MEDICAL ASSOCIATES A MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | LAKESIDE COMMUNITY HEALTHCARE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 FLOWER ST STE A | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912013000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186372000 | ||||||||
| FaxNumber: | 8182428761 | ||||||||
| Practice Location | |||||||||
| Address1: | 7325 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WEST HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913071925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185953580 | ||||||||
| FaxNumber: | 8185953599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2008 | ||||||||
| LastUpdateDate: | 05/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | WEINER | ||||||||
| AuthorizedOfficialFirstName: | KERRY | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8186372000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1184884769 | 05 | CA | MEDICAID |