Basic Information
| Provider Information | |||||||||
| NPI: | 1043518236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSHORE ONCOLOGY ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4950 ESSEN LANE | ||||||||
| Address2: | ATTN KRISTI SIEMANN | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252151311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1203 S TYLER ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704332353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858929090 | ||||||||
| FaxNumber: | 9858929957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2011 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | NOWACKI | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2252151223 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3855298 | 01 | MS | MISSISSIPPI MEDICAID | OTHER | 2142089 | 05 | LA | MEDICAID |