Basic Information
Provider Information | |||||||||
NPI: | 1033160973 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRESBYTERIAN BREAST CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRESBYTERIAN BREAST NORTHPOINT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2085 FRONTIS PLAZA BLVD | ||||||||
Address2: |   | ||||||||
City: | WINSTON-SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271035614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3362777226 | ||||||||
FaxNumber: | 3362779795 | ||||||||
Practice Location | |||||||||
Address1: | 16525 HOLLY CREST LN | ||||||||
Address2: | STE 130 | ||||||||
City: | HUNTERSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 280784909 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043844000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2006 | ||||||||
LastUpdateDate: | 10/26/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARGETT | ||||||||
AuthorizedOfficialFirstName: | FRED | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | EVP CFO | ||||||||
AuthorizedOfficialTelephone: | 7043845184 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography |
ID Information
ID | Type | State | Issuer | Description | 16-42367 | 01 |   | UHC | OTHER | 89016K8 | 05 | NC |   | MEDICAID |