Provider Demographics
NPI:1043388861
Name:SOUTHERN UTAH MRI, INC.
Entity Type:Organization
Organization Name:SOUTHERN UTAH MRI, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:G
Authorized Official - Last Name:DELCORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-586-1003
Mailing Address - Street 1:1335 N. NORTHFIELD RD.
Mailing Address - Street 2:#100
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721
Mailing Address - Country:US
Mailing Address - Phone:435-865-9293
Mailing Address - Fax:435-867-9848
Practice Address - Street 1:1335 N. NORTHFIELD RD.
Practice Address - Street 2:#100
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721
Practice Address - Country:US
Practice Address - Phone:435-865-9293
Practice Address - Fax:435-867-9848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QM1200X
261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========-006Medicaid
UT=========-006Medicaid