Healthcare Provider Details

I. General information

NPI: 1851409874
Provider Name (Legal Business Name): LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 05/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W EULALIA ST SUITE 200
GLENDALE CA
91204-2849
US

IV. Provider business mailing address

777 FLOWER ST SUITE A
GLENDALE CA
91201-3015
US

V. Phone/Fax

Practice location:
  • Phone: 818-291-4010
  • Fax: 818-291-4058
Mailing address:
  • Phone: 818-637-2000
  • Fax: 818-242-8761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

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