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NPI Code Detail

MEDICARE: BREAST DIAGNOSTIC CENTER, LLC

MEDICARE: BREAST DIAGNOSTIC 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
12085R0202XDiagnostic Radiology Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1790748499
Entity Type Code : Organization
Provider Name (Legal Business Name) : BREAST DIAGNOSTIC CENTER, LLC
Provider Business Mailing Address
First Line : 3707 NEW VISION DR
Second Line :
City : FORT WAYNE
State : IN
Zip : 46845-1702
Country : US
Telephone Number : 260-471-9466
Fax Number : 260-484-5919
Provider Business Practice Location Address
First Line : 3707 NEW VISION DR
Second Line :
City : FORT WAYNE
State : IN
Zip : 46845-1702
Country : US
Telephone Number : 260-471-9466
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : DR. ADAM M GREGORY
Credential : M.D.
Telephone Number : 260-471-9466
Provider Enumeration Date : 04/11/2006
Last Update Date : 09/24/2024

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Directions to “BREAST DIAGNOSTIC CENTER, LLC ” Practice Location

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