Provider Demographics
NPI:1649499427
Name:BREAST CARE SPECIALISTS PC
Entity type:Organization
Organization Name:BREAST CARE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-622-8032
Mailing Address - Street 1:5900 LAKE WRIGHT DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-1871
Mailing Address - Country:US
Mailing Address - Phone:757-622-8032
Mailing Address - Fax:757-625-7016
Practice Address - Street 1:5900 LAKE WRIGHT DR
Practice Address - Street 2:SUITE 201
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-1871
Practice Address - Country:US
Practice Address - Phone:757-622-8032
Practice Address - Fax:757-625-7016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA250256OtherANTHEM BC BS
NC0695AOtherANTHEM BC BS OF NC
VARR020018463OtherMEDICARE RAILROAD
VAF27337Medicare UPIN