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General NPI Number Information
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NPI Number | 1851409874
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Entity Type | Organization
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Legal Business Name | LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 05/12/2009
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Provider Practice Location Address
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Address Line | 222 W EULALIA ST SUITE 200
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City | GLENDALE
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State | CA
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Zip | 91204-2849
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Country | US
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Telephone | 818-291-4010
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Fax | 818-291-4058
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Provider Business Mailing Address
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Address Line | 777 FLOWER ST SUITE A
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City | GLENDALE
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State | CA
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Zip | 91201-3015
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Country | US
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Telephone | 818-637-2000
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Fax | 818-242-8761
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KERRY E. WEINER
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Credential | M.D.
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Telephone | 818-637-2000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number |
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License Number State |
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