Healthcare Provider Details

I. General information

NPI: 1427633197
Provider Name (Legal Business Name): ELLIOTT BREAST CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 SHADOWS LN STE C
BATON ROUGE LA
70806-6559
US

IV. Provider business mailing address

541 SHADOWS LN STE C
BATON ROUGE LA
70806-6559
US

V. Phone/Fax

Practice location:
  • Phone: 225-755-3070
  • Fax: 225-755-3085
Mailing address:
  • Phone: 225-906-2621
  • Fax: 225-755-3085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CATHERINE C BAUCOM
Title or Position: OWNER
Credential: MD, PH.D
Phone: 225-755-3070