=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861216772
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY BIRD PERKINS CANCER CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2024
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4950 ESSEN LN
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70809-3738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-767-0847
-----------------------------------------------------
Fax | 225-767-1335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5215 ESSEN LN STE 200
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70809-3543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-215-1281
-----------------------------------------------------
Fax | 225-215-1380
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DECISION SUPPORT MANAGER
-----------------------------------------------------
Name | JACOB KRAFT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-215-1281
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------