1356643399 NPI number — OUR LADY OF THE LAKE PHYSICIAN GROUP LLC

Table of content: (NPI 1356643399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356643399 NPI number — OUR LADY OF THE LAKE PHYSICIAN GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUR LADY OF THE LAKE PHYSICIAN GROUP LLC
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:
LAKE PHYSICIAN GROUP CARDIOLOGY SER
Provider Other Organization Name Type Code:
3
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:
1356643399
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8415 GOODWOOD BLVD
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70806-7851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-765-5727
Provider Business Mailing Address Fax Number:
225-765-4278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8415 GOODWOOD BLVD
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70806-7851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-765-5727
Provider Business Practice Location Address Fax Number:
225-765-4278
Provider Enumeration Date:
11/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SHARBAUGH
Authorized Official First Name:
ELONA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP PHYSICIAN PRACTICES
Authorized Official Telephone Number:
225-765-8680

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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