Basic Information
| Provider Information | |||||||||
| NPI: | 1063748929 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS FOR BREAST HEALTH, L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3262 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658083262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178853888 | ||||||||
| FaxNumber: | 4178817638 | ||||||||
| Practice Location | |||||||||
| Address1: | 3850 S NATIONAL AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172696170 | ||||||||
| FaxNumber: | 4172696992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2009 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | BARRETT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4172696170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.