Provider Demographics
NPI:1144211582
Name:TULSA X-RAY LABORATORY INC
Entity Type:Organization
Organization Name:TULSA X-RAY LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:R
Authorized Official - Last Name:NORRED
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:918-829-8328
Mailing Address - Street 1:PO BOX 52550
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74152-0550
Mailing Address - Country:US
Mailing Address - Phone:918-934-8347
Mailing Address - Fax:918-917-4114
Practice Address - Street 1:1120 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-934-8347
Practice Address - Fax:918-917-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100729370AMedicaid
OKCD9316Medicare PIN
OK=========Medicare PIN