Provider Demographics
NPI:1770543076
Name:LAKE AREA PHYSICIAN SERVICES LLC
Entity type:Organization
Organization Name:LAKE AREA PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:4200 NELSON RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4118
Mailing Address - Country:US
Mailing Address - Phone:377-474-6370
Mailing Address - Fax:337-475-4143
Practice Address - Street 1:4200 NELSON RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4118
Practice Address - Country:US
Practice Address - Phone:337-474-6370
Practice Address - Fax:337-475-4143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1442682Medicaid
LA1442682Medicaid