Provider Demographics
NPI:1972645216
Name:OUR LADY OF THE LAKE REGIONAL MEDICA
Entity Type:Organization
Organization Name:OUR LADY OF THE LAKE REGIONAL MEDICA
Other - Org Name:OUR LADY OF THE LAKE HOSPITAL INC PEDIATRIC PULMONARY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-765-4251
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:225-413-4361
Mailing Address - Fax:225-765-4062
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:PLAZA 1 SUITE 406
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810
Practice Address - Country:US
Practice Address - Phone:225-765-3456
Practice Address - Fax:225-765-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445584Medicaid
LA5H580Medicare ID - Type Unspecified