Provider Demographics
NPI:1154366029
Name:BREAST CARE PC
Entity type:Organization
Organization Name:BREAST CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTI
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-971-5002
Mailing Address - Street 1:16620 N 40TH ST
Mailing Address - Street 2:STE. H3
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3348
Mailing Address - Country:US
Mailing Address - Phone:602-971-5002
Mailing Address - Fax:602-368-4638
Practice Address - Street 1:16620 N 40TH ST
Practice Address - Street 2:STE. H3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3348
Practice Address - Country:US
Practice Address - Phone:602-971-5002
Practice Address - Fax:602-368-4638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19443208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ71725Medicare PIN