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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
1207R00000XInternal Medicine Physician
2207Q00000XFamily Medicine Physician

Other Identifiers

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

General Provider Information

NPI Number : 1104087774
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 : 4955 VAN NUYS BLVD
Second Line : SUITE 308
City : SHERMAN OAKS
State : CA
Zip : 91403-1811
Country : US
Telephone Number : 818-907-5088
Fax Number : 818-907-5891
Authorized Official
Title or Position : PRESIDENT
Name : KERRY E WEINER
Credential : MD
Telephone Number : 818-637-2000
Provider Enumeration Date : 06/17/2008
Last Update Date : 05/06/2009

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Directions to “LAKESIDE MEDICAL ASSOCIATES A MEDICAL GROUP INC ” Practice Location

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