Basic Information
| Provider Information | |||||||||
| NPI: | 1356643399 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUR LADY OF THE LAKE PHYSICIAN GROUP LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE PHYSICIAN GROUP CARDIOLOGY SER | ||||||||
| 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: | 8415 GOODWOOD BLVD | ||||||||
| Address2: | STE 105 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708067851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655727 | ||||||||
| FaxNumber: | 2257654278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2010 | ||||||||
| LastUpdateDate: | 11/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | SHARBAUGH | ||||||||
| AuthorizedOfficialFirstName: | ELONA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP PHYSICIAN PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 2257658680 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OUR LADY OF THE LAKE PHYSICIAN GROUP LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.