Provider Demographics
NPI:1043518236
Name:NORTHSHORE ONCOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:NORTHSHORE ONCOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:NOWACKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-215-1223
Mailing Address - Street 1:4950 ESSEN LANE
Mailing Address - Street 2:ATTN KRISTI SIEMANN
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3482
Mailing Address - Country:US
Mailing Address - Phone:225-215-1311
Mailing Address - Fax:
Practice Address - Street 1:1203 S TYLER ST
Practice Address - Street 2:STE 100
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2353
Practice Address - Country:US
Practice Address - Phone:985-892-9090
Practice Address - Fax:985-892-9957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3855298OtherMISSISSIPPI MEDICAID
LA2142089Medicaid
LA2142089Medicaid