Healthcare Provider Details

I. General information

NPI: 1952355125
Provider Name (Legal Business Name): OUR LADY OF THE LAKE HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 HENNESSY BLVD
BATON ROUGE LA
70808-4375
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 225-766-5204
  • Fax: 225-765-4062
Mailing address:
  • Phone: 225-765-4226
  • Fax: 225-765-9244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMARA WHITE
Title or Position: DIRECTOR OF BUSINESS SERVICES
Credential:
Phone: 225-765-4251