MEDICARE: LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	207R00000X	Internal Medicine Physician
2	207RR0500X	Rheumatology Physician
3	208000000X	Pediatrics Physician
4	363L00000X	Nurse Practitioner	CA
5	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043256027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	777 FLOWER ST
Second Line	:	SUITE A
City	:	GLENDALE
State	:	CA
Zip	:	91201-3015
Country	:	US
Telephone Number	:	818-637-2000
Fax Number	:	818-242-8761

Provider Business Practice Location Address
First Line	:	607 S GLENOAKS BLVD
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91502-1424
Country	:	US
Telephone Number	:	818-557-2671
Fax Number	:	818-557-0761

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KERRY E. WEINER
Credential	:	M.D.
Telephone Number	:	818-637-2000

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	05/12/2009

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