Provider Demographics
NPI:1811011695
Name:ADVANCED BREAST CARE PC
Entity Type:Organization
Organization Name:ADVANCED BREAST CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:FINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-422-1988
Mailing Address - Street 1:790 CHURCH ST NE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7282
Mailing Address - Country:US
Mailing Address - Phone:770-422-1988
Mailing Address - Fax:770-874-0226
Practice Address - Street 1:790 CHURCH ST NE
Practice Address - Street 2:SUITE 410
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7282
Practice Address - Country:US
Practice Address - Phone:770-422-1988
Practice Address - Fax:770-874-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA91ZCBCSMedicare ID - Type Unspecified
GAF15000Medicare UPIN