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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QR0206X  Y Ambulatory Health Care FacilitiesClinic/CenterRadiology, Mammography

ID Information
IDTypeStateIssuerDescription
16-4236701 UHCOTHER
89016K805NC MEDICAID


Home