# OUR LADY OF THE LAKE PHYSICIAN GROUP LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1033494943
- **Authorized official:** JEFFREY LIMBOCKER (CFO)
- **Authorized official phone:** (225) 765-7727

## Contact information

- **Practice address:** 7777 HENNESSY BLVD, STE 6002, BATON ROUGE, LA 70808-4300
- **Practice address phone:** (225) 765-7727
- **Practice address fax:** (225) 766-5645
- **Mailing address:** 2051 SILVERSIDE DR, STE 260, BATON ROUGE, LA 70808-9005
- **Mailing address phone:** (225) 490-6301
- **Mailing address fax:** (225) 765-9539

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207K00000X | Allergy & Immunology Physician | — | NULL | — |
| 207K00000X | Allergy & Immunology Physician | — | — | — |
| 207N00000X | Dermatology Physician | — | NULL | — |
| 207N00000X | Dermatology Physician | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 207R00000X | Internal Medicine Physician | — | NULL | Yes |
| 207R00000X | Internal Medicine Physician | — | — | Yes |
| 207SG0201X | Clinical Genetics (M.D.) Physician | — | NULL | — |
| 207SG0201X | Clinical Genetics (M.D.) Physician | — | — | — |
| 207Y00000X | Otolaryngology Physician | — | NULL | — |
| 207Y00000X | Otolaryngology Physician | — | — | — |
| 208000000X | Pediatrics Physician | — | NULL | — |
| 208000000X | Pediatrics Physician | — | — | — |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | NULL | — |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | — |
| 208200000X | Plastic Surgery Physician | — | NULL | — |
| 208200000X | Plastic Surgery Physician | — | — | — |
| 2084P0800X | Psychiatry Physician | — | NULL | — |
| 2084P0800X | Psychiatry Physician | — | — | — |
| 208600000X | Surgery Physician | — | NULL | — |
| 208600000X | Surgery Physician | — | — | — |
| 208C00000X | Colon & Rectal Surgery Physician | — | NULL | — |
| 208C00000X | Colon & Rectal Surgery Physician | — | — | — |
| 208M00000X | Hospitalist Physician | — | NULL | — |
| 208M00000X | Hospitalist Physician | — | — | — |
| 363A00000X | Physician Assistant | — | NULL | — |
| 363A00000X | Physician Assistant | — | — | — |
| 363L00000X | Nurse Practitioner | — | NULL | — |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 10/12/2011
- **Last updated:** 10/08/2015