Healthcare Provider Details

I. General information

NPI: 1275577603
Provider Name (Legal Business Name): OUR LADY OF THE LAKE HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 225-765-5727
  • Fax: 225-765-9244
Mailing address:
  • Phone: 225-765-5727
  • Fax: 225-765-9244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. JAMY RICHARD
Title or Position: DIR OF REIMBURSEMENT AND FINANCE
Credential:
Phone: 225-765-4281