Healthcare Provider Details

I. General information

NPI: 1184671455
Provider Name (Legal Business Name): OUR LADY OF THE LAKE PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 ESSEN LN
BATON ROUGE LA
70809-3738
US

IV. Provider business mailing address

8415 GOODWOOD BLVD STE 105
BATON ROUGE LA
70806-7851
US

V. Phone/Fax

Practice location:
  • Phone: 225-767-1311
  • Fax: 225-767-1335
Mailing address:
  • Phone: 225-765-5727
  • Fax: 225-765-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TAMARA WHITE
Title or Position: DIRECTOR OF BUSINESS SERVICES
Credential:
Phone: 225-765-5727