Provider Demographics
NPI:1093947905
Name:OUR LADY OF THE LAKE HOSPITAL, INC
Entity Type:Organization
Organization Name:OUR LADY OF THE LAKE HOSPITAL, INC
Other - Org Name:PEDIATRIC SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LIMBOCKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:225-765-6306
Mailing Address - Street 1:8415 GOODWOOD BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7851
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-4278
Practice Address - Street 1:5000 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4375
Practice Address - Country:US
Practice Address - Phone:225-765-7163
Practice Address - Fax:225-765-7164
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE LAKE HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-12
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447129Medicaid
MS08775372Medicaid
MS08775372Medicaid