Healthcare Provider Details

I. General information

NPI: 1316953029
Provider Name (Legal Business Name): LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S FIRST STREET SUITE 1800
BURBANK CA
91502-1938
US

IV. Provider business mailing address

777 FLOWER ST STE A
GLENDALE CA
91201-3000
US

V. Phone/Fax

Practice location:
  • Phone: 818-558-7252
  • Fax: 818-558-7312
Mailing address:
  • Phone: 818-637-2000
  • Fax: 818-242-8761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. KERRY E. WEINER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-637-2000