Basic Information
| Provider Information | |||||||||
| NPI: | 1740516236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESIDE MEDICAL ASSOICATES, 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: | 1135 S SUNSET AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268562215 | ||||||||
| FaxNumber: | 6269602125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2009 | ||||||||
| LastUpdateDate: | 10/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | WEINER | ||||||||
| AuthorizedOfficialFirstName: | KERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8186372000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.