Provider Demographics
NPI:1275584179
Name:PRESBYTERIAN BREAST CENTER LLC
Entity Type:Organization
Organization Name:PRESBYTERIAN BREAST CENTER LLC
Other - Org Name:PRESBYTERIAN BREAST CENTER BALLANTYNE
Other - Org Type:Doing Business As
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 1:14215 BALLANTYNE CORPORATE PLACE
Practice Address - Street 2:STE 140
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3146
Practice Address - Country:US
Practice Address - Phone:704-384-1890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00191119OtherRAILROAD MEDICARE