Healthcare Provider Details

I. General information

NPI: 1043518236
Provider Name (Legal Business Name): NORTHSHORE ONCOLOGY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 S TYLER ST STE 100
COVINGTON LA
70433-2353
US

IV. Provider business mailing address

4950 ESSEN LANE ATTN KRISTI SIEMANN
BATON ROUGE LA
70809-3482
US

V. Phone/Fax

Practice location:
  • Phone: 985-892-9090
  • Fax: 985-892-9957
Mailing address:
  • Phone: 225-215-1311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL R NOWACKI
Title or Position: BUSINESS MANAGER
Credential:
Phone: 225-215-1223