=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689010167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKSTONE COMPREHENSIVE BREAST CARE CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2013
-----------------------------------------------------
Last Update Date | 05/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 CENTRE BROOK CT
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31904-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-507-7055
-----------------------------------------------------
Fax | 706-507-7056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 CENTRE BROOK CT
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31904-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-507-7055
-----------------------------------------------------
Fax | 706-507-7056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | RICHARD R. BLOOM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 706-507-7055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0206X
-----------------------------------------------------
Taxonomy Name | Mammography Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------