1184671455 NPI number — OUR LADY OF THE LAKE PHYSICIAN GROUP LLC

Table of content: (NPI 1184671455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184671455 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:
OLOL PHYSICIAN SURGICAL SPECIALTY
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:
1184671455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2013
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:
4950 ESSEN LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-3738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-767-1311
Provider Business Practice Location Address Fax Number:
225-767-1335
Provider Enumeration Date:
05/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BUSINESS SERVICES
Authorized Official Telephone Number:
225-765-5727

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 05684711 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1447218 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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