1104087774 NPI number — LAKESIDE MEDICAL ASSOCIATES A MEDICAL GROUP INC

Table of content: (NPI 1104087774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104087774 NPI number — LAKESIDE MEDICAL ASSOCIATES A MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE MEDICAL ASSOCIATES A MEDICAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104087774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 FLOWER STREET
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91201-3000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-637-2000
Provider Business Mailing Address Fax Number:
818-242-8761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4955 VAN NUYS BLVD
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
SHERMAN OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91403-1811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-907-5088
Provider Business Practice Location Address Fax Number:
818-907-5891
Provider Enumeration Date:
06/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WEINER
Authorized Official First Name:
KERRY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-637-2000

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1104087774 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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