Provider Demographics
NPI:1285890467
Name:LAKEVIEW REGIONAL PHYSICIAN GROUP LLC
Entity type:Organization
Organization Name:LAKEVIEW REGIONAL PHYSICIAN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP VICE PRESIDENT/AO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:REBOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-377-5004
Mailing Address - Street 1:PO BOX 405453
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5453
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:
Practice Address - Street 1:130 LAKEVIEW CIRCLE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-0001
Practice Address - Country:US
Practice Address - Phone:985-892-6858
Practice Address - Fax:866-457-6080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1384313Medicaid
MS00837785Medicaid
MS00837785Medicaid