Provider Demographics
NPI:1578690285
Name:CAROLINA BREAST CENTER
Entity Type:Organization
Organization Name:CAROLINA BREAST CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:KATE
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-329-8990
Mailing Address - Street 1:154 AMENDMENT AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3156
Mailing Address - Country:US
Mailing Address - Phone:803-329-8990
Mailing Address - Fax:803-329-8991
Practice Address - Street 1:154 AMENDMENT AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3156
Practice Address - Country:US
Practice Address - Phone:803-329-8990
Practice Address - Fax:803-329-8991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9901314208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3753Medicaid
SCGP3753Medicaid