=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467620773
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROANOKE BREAST CARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2008
-----------------------------------------------------
Last Update Date | 02/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 HIGHLAND AVE SE STE 200
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24013-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-985-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3227 WHITE OAK RD SW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24014-1427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-342-6504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAMES G. MULLET
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 540-342-6504
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------