Basic Information
| Provider Information | |||||||||
| NPI: | 1295833580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY BIRD PERKINS CANCER CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4950 ESSEN LANE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252151223 | ||||||||
| FaxNumber: | 2257660218 | ||||||||
| Practice Location | |||||||||
| Address1: | 4950 ESSEN LANE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252151223 | ||||||||
| FaxNumber: | 2257660218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 12/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | NOWACKI | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2252151223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 8145644 | 01 | LA | AETNA | OTHER | 1116301 | 05 | LA | MEDICAID | CO1095 | 01 | LA | RR MEDICARE | OTHER |