Provider Demographics
NPI:1619155124
Name:ST. ELIZABETH-MARY BIRD PERKINS CANCER CENTER, L.L.C.
Entity Type:Organization
Organization Name:ST. ELIZABETH-MARY BIRD PERKINS CANCER CENTER, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
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:70809-3432
Mailing Address - Country:US
Mailing Address - Phone:225-215-1311
Mailing Address - Fax:225-766-0218
Practice Address - Street 1:1104 W HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5003
Practice Address - Country:US
Practice Address - Phone:225-215-1223
Practice Address - Fax:225-766-0218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1369306Medicaid
LA283061Medicare PIN