Healthcare Provider Details

I. General information

NPI: 1174662035
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: 02/06/2007
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 ROBERTS DR SUITE H
NEW ROADS LA
70760-2661
US

IV. Provider business mailing address

2051 SILVERSIDE DR SUITE 120
BATON ROUGE LA
70808-9005
US

V. Phone/Fax

Practice location:
  • Phone: 225-638-7033
  • Fax: 225-638-7034
Mailing address:
  • Phone: 225-765-4226
  • Fax: 225-765-9244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: ELONA SHARBAUGH
Title or Position: VP PHYSICIAN PRACTICES
Credential:
Phone: 225-490-8806