1841281631 NPI number — BERTRAND DIAGNOSTIC IMAGING AND BREAST CENTER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841281631 NPI number — BERTRAND DIAGNOSTIC IMAGING AND BREAST CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERTRAND DIAGNOSTIC IMAGING AND BREAST CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841281631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6730565
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75373-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-613-5807
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1126 N CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27401-1000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-379-0941
Provider Business Practice Location Address Fax Number:
336-379-7997
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KANEWSKE
Authorized Official First Name:
EILEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR PT. ACCOUNTS
Authorized Official Telephone Number:
512-340-8114

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  20236 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 890270A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0270A . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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