MEDICARE: NEXT GEN BREAST IMAGING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0206X	Mammography Clinic/Center

General Provider Information

NPI Number	:	1134597966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEXT GEN BREAST IMAGING LLC

Provider Business Mailing Address
First Line	:	1942 E DUPONT RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1582
Country	:	US
Telephone Number	:	260-451-0286
Fax Number	:

Provider Business Practice Location Address
First Line	:	1942 E DUPONT RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1582
Country	:	US
Telephone Number	:	260-451-0286
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BUSHRA RASHID
Credential	:
Telephone Number	:	260-451-0286

Provider Enumeration Date	:	09/10/2015
Last Update Date	:	09/17/2015

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