Provider Demographics
NPI:1750577821
Name:BREAST TREATMENT ASSOCIATES, P.A.
Entity type:Organization
Organization Name:BREAST TREATMENT ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:I
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-582-1000
Mailing Address - Street 1:1792 E JOYCE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5255
Mailing Address - Country:US
Mailing Address - Phone:479-582-1000
Mailing Address - Fax:479-582-5724
Practice Address - Street 1:1792 E JOYCE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5255
Practice Address - Country:US
Practice Address - Phone:479-582-1000
Practice Address - Fax:479-582-5724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC1480174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR124294002Medicaid