Healthcare Provider Details

I. General information

NPI: 1972645216
Provider Name (Legal Business Name): OUR LADY OF THE LAKE REGIONAL MEDICA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 HENNESSY BLVD PLAZA 1 SUITE 406
BATON ROUGE LA
70810
US

IV. Provider business mailing address

8415 GOODWOOD BLVD SUITE 105
BATON ROUGE LA
70806
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-3456
  • Fax: 225-765-1899
Mailing address:
  • Phone: 225-413-4361
  • Fax: 225-765-4062

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