Basic Information
| Provider Information | |||||||||
| NPI: | 1659576072 | ||||||||
| 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: | 1500 S CENTRAL AVE | ||||||||
| Address2: | SUITE 326 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912042530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189568582 | ||||||||
| FaxNumber: | 8189560329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2007 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | WEINER | ||||||||
| AuthorizedOfficialFirstName: | KERRY | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8186372000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | GR006838C | 05 | CA | MEDICAID |