Provider Demographics
NPI:1841281631
Name:BERTRAND DIAGNOSTIC IMAGING AND BREAST CENTER, INC.
Entity type:Organization
Organization Name:BERTRAND DIAGNOSTIC IMAGING AND BREAST CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PT. ACCOUNTS
Authorized Official - Prefix:MS
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KANEWSKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-340-8114
Mailing Address - Street 1:PO BOX 6730565
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-0001
Mailing Address - Country:US
Mailing Address - Phone:866-613-5807
Mailing Address - Fax:
Practice Address - Street 1:1126 N CHURCH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1000
Practice Address - Country:US
Practice Address - Phone:336-379-0941
Practice Address - Fax:336-379-7997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20236174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890270AMedicaid
NC0270AOtherBLUE CROSS PROVIDER NUMBE
NCC82395Medicare UPIN
NC890270AMedicaid
NC204311Medicare PIN