Provider Demographics
NPI:1912282831
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:PEDIATRIC EMERGENCY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIMBOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-765-7727
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:STE 6002
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-765-7727
Mailing Address - Fax:225-766-5645
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:STE 6002
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-7727
Practice Address - Fax:225-766-5645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency MedicineGroup - Single Specialty