Basic Information
| Provider Information | |||||||||
| NPI: | 1447399308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUR LADY OF THE LAKE PHYSICIAN GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255260006 | ||||||||
| FaxNumber: | 2257659291 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 DUREL DR | ||||||||
| Address2: | |||||||||
| City: | NEW ROADS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707602973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257132400 | ||||||||
| FaxNumber: | 2257132405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | RICHARD | ||||||||
| AuthorizedOfficialFirstName: | JAMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2254908801 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OUR LADY OF THE LAKE HOSPITAL INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | AP07361 | LA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1447528 | 05 | LA | MEDICAID |