Provider Demographics
NPI:1326187477
Name:MEDICAL XRAY CENTER PC
Entity Type:Organization
Organization Name:MEDICAL XRAY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-731-7522
Mailing Address - Street 1:1417 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1715
Mailing Address - Country:US
Mailing Address - Phone:605-336-0517
Mailing Address - Fax:605-336-2874
Practice Address - Street 1:1417 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1715
Practice Address - Country:US
Practice Address - Phone:605-336-0517
Practice Address - Fax:605-336-2874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7202240Medicaid
MNC06137Medicare PIN
CI6167Medicare PIN
SD7202240Medicaid
CR0379Medicare PIN