MEDICARE: PRESBYTERIAN BREAST CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0206X	Mammography Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00191119	OTHER		RAILROAD MEDICARE

General Provider Information

NPI Number	:	1275584179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESBYTERIAN BREAST CENTER LLC

Provider Business Mailing Address
First Line	:	2085 FRONTIS PLAZA BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-5614
Country	:	US
Telephone Number	:	336-277-7226
Fax Number	:	336-277-9795

Provider Business Practice Location Address
First Line	:	14215 BALLANTYNE CORPORATE PLACE
Second Line	:	STE 140
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-3146
Country	:	US
Telephone Number	:	704-384-1890
Fax Number	:

Authorized Official
Title or Position	:	EVP CFO
Name	:	FRED M HARGETT
Credential	:
Telephone Number	:	704-384-5184

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	12/01/2010

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Directions to “PRESBYTERIAN BREAST CENTER LLC ” Practice Location

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