Provider Demographics
NPI:1326180696
Name:OUR LADY OF THE LAKE HOSPITAL INC
Entity Type:Organization
Organization Name:OUR LADY OF THE LAKE HOSPITAL INC
Other - Org Name:OLOL COMPREHENSIVE CHRONIC CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-765-8802
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
Mailing Address - Country:US
Mailing Address - Phone:225-765-4361
Mailing Address - Fax:225-765-4062
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:PLAZA 1 SUITE 306
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808
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:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1150436Medicaid
LA=========OtherTAX ID NUMBER
LA1150436Medicaid