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NPI Code Detail

MEDICARE: OUR LADY OF THE LAKE PHYSICIAN GROUP LLC

MEDICARE: OUR LADY OF THE LAKE PHYSICIAN GROUP LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant
2363LF0000XFamily Nurse PractitionerAP07361LA
3207Q00000XFamily Medicine Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1447399308
Entity Type Code : Organization
Provider Name (Legal Business Name) : OUR LADY OF THE LAKE PHYSICIAN GROUP LLC
Provider Business Mailing Address
First Line : 5959 S SHERWOOD FOREST BLVD
Second Line :
City : BATON ROUGE
State : LA
Zip : 70816-6038
Country : US
Telephone Number : 225-526-0006
Fax Number : 225-765-9291
Provider Business Practice Location Address
First Line : 310 DUREL DR
Second Line :
City : NEW ROADS
State : LA
Zip : 70760-2973
Country : US
Telephone Number : 225-713-2400
Fax Number : 225-713-2405
Authorized Official
Title or Position : VP FINANCE
Name : JAMY RICHARD
Credential :
Telephone Number : 225-490-8801
Provider Enumeration Date : 02/06/2007
Last Update Date : 07/28/2016

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Directions to “OUR LADY OF THE LAKE PHYSICIAN GROUP LLC ” Practice Location

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