Provider Demographics
NPI:1366448458
Name:NORTHLAKE NEPHROLOGY INC
Entity Type:Organization
Organization Name:NORTHLAKE NEPHROLOGY INC
Other - Org Name:NORTHLAKE NEPHROLOGY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-400-5988
Mailing Address - Street 1:PO BOX 3370
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70434-3370
Mailing Address - Country:US
Mailing Address - Phone:985-400-5988
Mailing Address - Fax:985-256-5687
Practice Address - Street 1:1970 N HWY 190
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433
Practice Address - Country:US
Practice Address - Phone:985-400-5988
Practice Address - Fax:985-256-5687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1442577Medicaid
MS08033237Medicaid
LA5C866Medicare PIN
MS08033237Medicaid