Healthcare Provider Details

I. General information

NPI: 1093769424
Provider Name (Legal Business Name): CHARLESTON BREAST CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 CHARLIE HALL BLVD
CHARLESTON SC
29414-5837
US

IV. Provider business mailing address

1930 CHARLIE HALL BLVD
CHARLESTON SC
29414-5837
US

V. Phone/Fax

Practice location:
  • Phone: 843-556-0036
  • Fax: 843-556-3844
Mailing address:
  • Phone: 843-556-0036
  • Fax: 843-556-3844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number14926
License Number StateSC

VIII. Authorized Official

Name: DR. LISA F BARON
Title or Position: PRACTICE MANAGER
Credential: MD
Phone: 843-556-0036