Provider Demographics
NPI:1518006568
Name:OUR LADY OF THE LAKE PHYSICIAN GROUP LLC
Entity Type:Organization
Organization Name:OUR LADY OF THE LAKE PHYSICIAN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP PHYSICIAN PRACTICES
Authorized Official - Prefix:
Authorized Official - First Name:ELONA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-490-8806
Mailing Address - Street 1:2051 SILVERSIDE DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-9005
Mailing Address - Country:US
Mailing Address - Phone:225-765-4226
Mailing Address - Fax:225-765-9244
Practice Address - Street 1:160 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEW ROADS
Practice Address - State:LA
Practice Address - Zip Code:70760-2617
Practice Address - Country:US
Practice Address - Phone:225-638-4686
Practice Address - Fax:225-638-4203
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE LAKE HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-06
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447536Medicaid
LA1447536Medicaid