Provider Demographics
NPI:1235263724
Name:OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER
Other - Org Name:OUR LADY OF THE LAKE HOSPITAL INC PEDIATRIC PULMONARY CLINIC SLEEP LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-765-3456
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:PLAZE 1 STE 406
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-765-3456
Mailing Address - Fax:225-765-1899
Practice Address - Street 1:8415 GOODWOOD BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7851
Practice Address - Country:US
Practice Address - Phone:225-765-4361
Practice Address - Fax:225-765-4062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445584Medicaid
LA1445584Medicaid
LA=========OtherTAX IDENTIFICATION