Basic Information
| Provider Information | |||||||||
| NPI: | 1265561575 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | A I ADVANCE IMAGING OF TULSA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6757 S YALE AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185230002 | ||||||||
| FaxNumber: | 9185230030 | ||||||||
| Practice Location | |||||||||
| Address1: | 6757 S YALE AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185230002 | ||||||||
| FaxNumber: | 9185230030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2007 | ||||||||
| LastUpdateDate: | 04/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMACK | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9185230002 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200123150A | 05 | OK | MEDICAID |