Provider Demographics
NPI: | 1033494943 |
---|---|
Name: | OUR LADY OF THE LAKE PHYSICIAN GROUP LLC |
Entity Type: | Organization |
Organization Name: | OUR LADY OF THE LAKE PHYSICIAN GROUP LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JEFFREY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LIMBOCKER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 225-765-7727 |
Mailing Address - Street 1: | 2051 SILVERSIDE DR |
Mailing Address - Street 2: | STE 260 |
Mailing Address - City: | BATON ROUGE |
Mailing Address - State: | LA |
Mailing Address - Zip Code: | 70808-9005 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 225-490-6301 |
Mailing Address - Fax: | 225-765-9539 |
Practice Address - Street 1: | 7777 HENNESSY BLVD |
Practice Address - Street 2: | STE 6002 |
Practice Address - City: | BATON ROUGE |
Practice Address - State: | LA |
Practice Address - Zip Code: | 70808-4300 |
Practice Address - Country: | US |
Practice Address - Phone: | 225-765-7727 |
Practice Address - Fax: | 225-766-5645 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-10-12 |
Last Update Date: | 2015-10-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207SG0201X | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | Group - Multi-Specialty |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208C00000X | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | Group - Multi-Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
LA | 2305042 | Medicaid | |
LA | 5DX80 | Medicare PIN |