1518006568 NPI number — OUR LADY OF THE LAKE PHYSICIAN GROUP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518006568 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:
Provider Other Organization Name Type Code:
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:
1518006568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2051 SILVERSIDE DR
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70808-9005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-765-4226
Provider Business Mailing Address Fax Number:
225-765-9244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 HOSPITAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ROADS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70760-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-638-4686
Provider Business Practice Location Address Fax Number:
225-638-4203
Provider Enumeration Date:
02/06/2007

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:
225-490-8806

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; 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: 1447536 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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