Provider Demographics
NPI:1023005253
Name:ST VINCENT BREAST CANCER & MAMMOGRAPHY SCREENING CENTER LLC
Entity Type:Organization
Organization Name:ST VINCENT BREAST CANCER & MAMMOGRAPHY SCREENING CENTER LLC
Other - Org Name:ST VINCENT BREAST CANCER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:J
Authorized Official - Last Name:GEHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-686-2614
Mailing Address - Street 1:500 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5302
Mailing Address - Country:US
Mailing Address - Phone:501-661-9766
Mailing Address - Fax:501-975-4666
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5302
Practice Address - Country:US
Practice Address - Phone:501-661-9766
Practice Address - Fax:501-975-4666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C297Medicare ID - Type Unspecified