Basic Information
| Provider Information | |||||||||
| NPI: | 1093767246 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUR LADY OF THE LAKE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOSPITAL MEDICINE SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 HENNESSY BLVD | ||||||||
| Address2: | HOSPITAL MEDICINE SERVICE | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257654050 | ||||||||
| FaxNumber: | 2257654046 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 HENNESSY BLVD | ||||||||
| Address2: | HOSPITAL MEDICINE SERVICE | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257654050 | ||||||||
| FaxNumber: | 2257654046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 05/19/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | TAMARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2257654251 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1445479 | 05 | LA | MEDICAID |