Basic Information
| Provider Information | |||||||||
| NPI: | 1427242247 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME DIAGNOSTICS | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 N MAY AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731126641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056045613 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 N MAY AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731126641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056045613 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2007 | ||||||||
| LastUpdateDate: | 10/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | ALVIS | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4056045613 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 19195 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.