Healthcare Provider Details

I. General information

NPI: 1104001288
Provider Name (Legal Business Name): LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S CENTRAL AVE SUITE 320
GLENDALE CA
91204-2530
US

IV. Provider business mailing address

777 FLOWER ST SUITE A
GLENDALE CA
91201-3015
US

V. Phone/Fax

Practice location:
  • Phone: 818-247-3708
  • Fax: 818-547-3146
Mailing address:
  • Phone: 818-637-2000
  • Fax: 818-242-8761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

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