Basic Information
| Provider Information | |||||||||
| NPI: | 1356322754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGHLANDS BREAST & IMAGING CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144333 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328144333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074229831 | ||||||||
| FaxNumber: | 4076482065 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 MEDICAL CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | SEBRING | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338705423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633856655 | ||||||||
| FaxNumber: | 8633852282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | CARRUTHERS | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8633856655 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CB4926 | 01 | RAILROAD MEDICARE | OTHER | V3136 | 01 | FL | BLUE CROSS BLUE SHIELD OF FLORIDA | OTHER |