Basic Information
| Provider Information | |||||||||
| NPI: | 1205002862 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESIDE MEDICAL ASSOCIATES A MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAKESIDE COMMUNITY HEALTHCARE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 FLOWER STREET | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912013000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186372000 | ||||||||
| FaxNumber: | 8182428761 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 S CENTRAL AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912042500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182541511 | ||||||||
| FaxNumber: | 8182541500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEINER | ||||||||
| AuthorizedOfficialFirstName: | KERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8186372000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1205002862 | 05 | CA | MEDICAID |