Provider Demographics
NPI:1124372867
Name:TUSCALOOSA BREAST CENTER PC
Entity Type:Organization
Organization Name:TUSCALOOSA BREAST CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-752-2501
Mailing Address - Street 1:701 UNIVERSITY BLVD E
Mailing Address - Street 2:SUITE 606
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-2086
Mailing Address - Country:US
Mailing Address - Phone:205-752-2501
Mailing Address - Fax:205-759-2868
Practice Address - Street 1:701 UNIVERSITY BLVD E
Practice Address - Street 2:SUITE 606
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2086
Practice Address - Country:US
Practice Address - Phone:205-752-2501
Practice Address - Fax:205-759-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12102174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0000036823Medicaid
AL0000036823Medicaid
AL000036823Medicare PIN