Basic Information
| Provider Information | |||||||||
| NPI: | 1831426642 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESIDE MEDICAL ORGANIZATION, A MEDICAL GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8510 BALBOA BLVD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913253583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186372000 | ||||||||
| FaxNumber: | 8186543417 | ||||||||
| Practice Location | |||||||||
| Address1: | 8510 BALBOA BLVD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913253583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186372000 | ||||||||
| FaxNumber: | 8186543417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2009 | ||||||||
| LastUpdateDate: | 03/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | EPSTEIN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8186372000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.