Provider Demographics
NPI:1225274483
Name:MARY BIRD PERKINS CANCER CENTER
Entity Type:Organization
Organization Name:MARY BIRD PERKINS CANCER CENTER
Other - Org Name:MARY BIRD PERKINS CANCER CENTER MEDICAID GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
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 LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3738
Mailing Address - Country:US
Mailing Address - Phone:225-767-0847
Mailing Address - Fax:225-766-0218
Practice Address - Street 1:4950 ESSEN LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3738
Practice Address - Country:US
Practice Address - Phone:225-767-0847
Practice Address - Fax:225-766-0218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty