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NPI Code Detail

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

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 License Number State
1207V00000XObstetrics & Gynecology Physician

General Provider Information

NPI Number : 1104072339
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.
Provider Business Mailing Address
First Line : 777 FLOWER STREET
Second Line : SUITE A
City : GLENDALE
State : CA
Zip : 91201-3000
Country : US
Telephone Number : 818-637-2000
Fax Number : 818-242-8761
Provider Business Practice Location Address
First Line : 7345 MEDICAL CENTER DRIVE
Second Line : SUITE 500
City : WEST HILLS
State : CA
Zip : 91307-1964
Country : US
Telephone Number : 818-348-6200
Fax Number : 818-348-6233
Authorized Official
Title or Position : PRESIDENT
Name : KERRY E. WEINER
Credential : M.D.
Telephone Number : 818-637-2000
Provider Enumeration Date : 08/07/2008
Last Update Date : 05/06/2009

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