Healthcare Provider Details

I. General information

NPI: 1912282831
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: 10/12/2011
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 HENNESSY BLVD STE 6002
BATON ROUGE LA
70808-4300
US

IV. Provider business mailing address

7777 HENNESSY BLVD STE 6002
BATON ROUGE LA
70808-4300
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-7727
  • Fax: 225-766-5645
Mailing address:
  • Phone: 225-765-7727
  • Fax: 225-766-5645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY LIMBOCKER
Title or Position: CFO
Credential:
Phone: 225-765-7727