1104001288 NPI number — LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.

Table of content: (NPI 1104001288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104001288 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:
1104001288
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 FLOWER ST
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:
91201-3015
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:
1500 S CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91204-2530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-247-3708
Provider Business Practice Location Address Fax Number:
818-547-3146
Provider Enumeration Date:
01/08/2008

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: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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