MEDICARE: LAKE OLIVER EMERGENCY GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician
2	363A00000X	Physician Assistant
3	363L00000X	Nurse Practitioner
4	207P00000X	Emergency Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457012940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE OLIVER EMERGENCY GROUP, LLC

Provider Business Mailing Address
First Line	:	200 CORPORATE BLVD
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-3870
Country	:	US
Telephone Number	:	337-609-1153
Fax Number	:

Provider Business Practice Location Address
First Line	:	3157 N MONROE ST
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32303-2819
Country	:	US
Telephone Number	:	850-692-0300
Fax Number	:

Authorized Official
Title or Position	:	VP OF CONTRACTING
Name	:	LISHA C FALK
Credential	:
Telephone Number	:	337-609-1221

Provider Enumeration Date	:	01/06/2022
Last Update Date	:	09/27/2022

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