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General NPI Number Information
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NPI Number | 1942498050
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Entity Type | Organization
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Legal Business Name | THE BREAST CARE TEAM , PC
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Dates
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Enumeration Date | 10/15/2007
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Last Update Date | 12/19/2007
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Provider Practice Location Address
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Address Line | 130 RIVERSTONE TER SUITE 101
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City | CANTON
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State | GA
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Zip | 30114-1702
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Country | US
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Telephone | 770-704-6977
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Fax | 770-704-6169
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Provider Business Mailing Address
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Address Line | 130 RIVERSTONE TER SUITE 101
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City | CANTON
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State | GA
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Zip | 30114-1702
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Country | US
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Telephone | 770-704-6977
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Fax | 770-704-6169
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. ANITA T JOHNSON
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Credential |
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Telephone | 770-704-6977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086X0206X
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Taxonomy Name | Surgical Oncology Physician
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License Number | 053464
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License Number State | GA
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