Basic Information
| Provider Information | |||||||||
| NPI: | 1093947905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUR LADY OF THE LAKE HOSPITAL, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEDIATRIC SPECIALTY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8415 GOODWOOD BLVD | ||||||||
| Address2: | STE 105 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708067851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655727 | ||||||||
| FaxNumber: | 2257654278 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 HENNESSY BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257657163 | ||||||||
| FaxNumber: | 2257657164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2009 | ||||||||
| LastUpdateDate: | 04/15/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIMBOCKER | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2257656306 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OUR LADY OF THE LAKE HOSPITAL, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1447129 | 05 | LA | MEDICAID | 08775372 | 05 | MS | MEDICAID |