Basic Information
| Provider Information | |||||||||
| NPI: | 1285890467 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKEVIEW REGIONAL PHYSICIAN GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 405453 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303845453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 LAKEVIEW CIRCLE | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704330001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858926858 | ||||||||
| FaxNumber: | 8664576080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | REBOK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | GROUP VICE PRESIDENT/AO | ||||||||
| AuthorizedOfficialTelephone: | 6153775004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1384313 | 05 | LA | MEDICAID | 00837785 | 05 | MS | MEDICAID |