Healthcare Provider Details

I. General information

NPI: 1235263724
Provider Name (Legal Business Name): OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/22/2020
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

7777 HENNESSY BLVD PLAZE 1 STE 406
BATON ROUGE LA
70808-4300
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-4361
  • Fax: 225-765-4062
Mailing address:
  • Phone: 225-765-3456
  • Fax: 225-765-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID E THOMAS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 225-765-3456