Healthcare Provider Details

I. General information

NPI: 1023005253
Provider Name (Legal Business Name): ST VINCENT BREAST CANCER & MAMMOGRAPHY SCREENING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S UNIVERSITY AVE SUITE 114
LITTLE ROCK AR
72205-5302
US

IV. Provider business mailing address

500 S UNIVERSITY AVE SUITE 114
LITTLE ROCK AR
72205-5302
US

V. Phone/Fax

Practice location:
  • Phone: 501-661-9766
  • Fax: 501-975-4666
Mailing address:
  • Phone: 501-661-9766
  • Fax: 501-975-4666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JEROME J GEHL
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 501-686-2614