Provider Demographics
NPI:1356643399
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:<UNAVAIL>
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:225-765-8680
Mailing Address - Street 1:8415 GOODWOOD BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7851
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-4278
Practice Address - Street 1:8415 GOODWOOD BLVD
Practice Address - Street 2:STE 105
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7851
Practice Address - Country:US
Practice Address - Phone:225-765-5727
Practice Address - Fax:225-765-4278
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF THE LAKE PHYSICIAN GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-24
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty