1134152630 NPI number — OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC

Table of content: (NPI 1134152630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134152630 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:
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:
1134152630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18740 HIGHWAY 22
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAUREPAS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70449-3018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-698-3435
Provider Business Mailing Address Fax Number:
225-698-6446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18740 HIGHWAY 22
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAUREPAS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70449-3018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-698-3435
Provider Business Practice Location Address Fax Number:
225-698-6446
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARD
Authorized Official First Name:
JAMY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
VP FINANCE
Authorized Official Telephone Number:
225-526-0121

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: 115 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1408239 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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