Provider Demographics
NPI:1245208008
Name:PRAIRIE CREEK IMAGING LLC
Entity Type:Organization
Organization Name:PRAIRIE CREEK IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHURTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-262-1103
Mailing Address - Street 1:PO BOX 2854
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-2854
Mailing Address - Country:US
Mailing Address - Phone:316-685-3698
Mailing Address - Fax:
Practice Address - Street 1:500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3722
Practice Address - Country:US
Practice Address - Phone:316-262-1103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA5653OtherRAILROAD MEDICARE
KS110957OtherBCBS
KS110957OtherBCBS
=========OtherTRICARE