Provider Demographics
NPI:1447201017
Name:PRESBYTERIAN BREAST CENTER, LLC
Entity type:Organization
Organization Name:PRESBYTERIAN BREAST CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP CFO
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARGETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-384-5184
Mailing Address - Street 1:2085 FRONTIS PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5614
Mailing Address - Country:US
Mailing Address - Phone:336-277-7226
Mailing Address - Fax:336-277-9795
Practice Address - Street 1:10030 GILEAD RD
Practice Address - Street 2:STE 310 PHYSICIANS PLAZA
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7545
Practice Address - Country:US
Practice Address - Phone:704-316-5535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MammographyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917803Medicaid
NC2881786BOtherMEDICARE PTAN
NC615320501OtherNC DOL
P00191119OtherRAILROAD MEDICARE
16-02288OtherUHC