Provider Demographics
NPI:1275577603
Name:OUR LADY OF THE LAKE HOSPITAL INC
Entity Type:Organization
Organization Name:OUR LADY OF THE LAKE HOSPITAL INC
Other - Org Name:LAKE PRIMARY CARE PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF REIMBURSEMENT AND FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-765-4281
Mailing Address - Street 1:8415 GOODWOOD BLVD
Mailing Address - Street 2:SUITE 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:225-765-9244
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:225-765-5727
Practice Address - Fax:225-765-9244
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE LAKE HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1941913Medicaid
LACD9919OtherRAILROAD MEDICARE (GROUP)
LA5D279Medicare PIN