Provider Demographics
NPI:1093769424
Name:CHARLESTON BREAST CENTER, INC.
Entity Type:Organization
Organization Name:CHARLESTON BREAST CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:F
Authorized Official - Last Name:BARON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-556-0036
Mailing Address - Street 1:1930 CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5837
Mailing Address - Country:US
Mailing Address - Phone:843-556-0036
Mailing Address - Fax:843-556-3844
Practice Address - Street 1:1930 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5837
Practice Address - Country:US
Practice Address - Phone:843-556-0036
Practice Address - Fax:843-556-3844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC149262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4567Medicaid