Provider Demographics
NPI:1942310917
Name:THE PHILIP ISRAEL BREAST CENTER, P.C.
Entity Type:Organization
Organization Name:THE PHILIP ISRAEL BREAST CENTER, P.C.
Other - Org Name:THE BREAST CENTER, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MITZI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-428-4486
Mailing Address - Street 1:702 CANTON RD NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7271
Mailing Address - Country:US
Mailing Address - Phone:770-428-4486
Mailing Address - Fax:770-425-6008
Practice Address - Street 1:702 CANTON RD NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7271
Practice Address - Country:US
Practice Address - Phone:770-428-4486
Practice Address - Fax:770-425-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========Medicare ID - Type UnspecifiedTAX ID
GA=========Medicaid