Healthcare Provider Details

I. General information

NPI: 1447399308
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: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 DUREL DR
NEW ROADS LA
70760-2973
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-713-2400
  • Fax: 225-713-2405
Mailing address:
  • Phone: 225-526-0006
  • Fax: 225-765-9291

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
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP07361
License Number StateLA

VIII. Authorized Official

Name: JAMY RICHARD
Title or Position: VP FINANCE
Credential:
Phone: 225-490-8801