Provider Demographics
NPI:1417079682
Name:THE BREAST HEALTH CLINIC, PC.
Entity Type:Organization
Organization Name:THE BREAST HEALTH CLINIC, PC.
Other - Org Name:FKA STEPHEN P. AUDA, M.D., P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:AUDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-461-1337
Mailing Address - Street 1:325 NORTH JEFF DAVIS DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:770-461-1337
Mailing Address - Fax:770-461-0922
Practice Address - Street 1:325 NORTH JEFF DAVIS DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-461-1337
Practice Address - Fax:770-461-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
GA020653208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00186392AMedicaid
GA00186392AMedicaid