Healthcare Provider Details

I. General information

NPI: 1063428688
Provider Name (Legal Business Name): ST. JUDE CHILDREN'S RESEARCH HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 HENNESSY BLVD STE. 312
BATON ROUGE LA
70808-4300
US

IV. Provider business mailing address

7777 HENNESSY BLVD STE. 312
BATON ROUGE LA
70808-4300
US

V. Phone/Fax

Practice location:
  • Phone: 225-763-6337
  • Fax: 225-761-4072
Mailing address:
  • Phone: 225-763-6337
  • Fax: 225-761-4072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: MICHAEL C CANARIOS
Title or Position: VP/CFO
Credential:
Phone: 901-495-3006