Provider Demographics
NPI:1922504364
Name:ST LUKE'S MEDICAL GROUP OF LOUISIANA, LLC
Entity Type:Organization
Organization Name:ST LUKE'S MEDICAL GROUP OF LOUISIANA, LLC
Other - Org Name:ST. LUKE'S HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:124-839-7826
Mailing Address - Street 1:10473 OLD HAMMOND HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8264
Mailing Address - Country:US
Mailing Address - Phone:225-900-8924
Mailing Address - Fax:
Practice Address - Street 1:3955 GOVERNMENT ST STE 2
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-5755
Practice Address - Country:US
Practice Address - Phone:225-924-1910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2018-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303032207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty