Basic Information
| Provider Information | |||||||||
| NPI: | 1619155124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. ELIZABETH-MARY BIRD PERKINS CANCER CENTER, L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4950 ESSEN LN | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252151311 | ||||||||
| FaxNumber: | 2257660218 | ||||||||
| Practice Location | |||||||||
| Address1: | 1104 W HIGHWAY 30 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252151223 | ||||||||
| FaxNumber: | 2257660218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 07/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | NOWACKI | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2252151223 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 2085R0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1369306 | 05 | LA | MEDICAID |