Provider Demographics
NPI:1134497753
Name:PREMIER SPORTS IMAGING OF GLENDALE
Entity Type:Organization
Organization Name:PREMIER SPORTS IMAGING OF GLENDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HISCOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-533-4465
Mailing Address - Street 1:PO BOX 27340
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85061-7340
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:7111 W BELL RD STE 104
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8552
Practice Address - Country:US
Practice Address - Phone:602-943-9200
Practice Address - Fax:602-216-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty