Provider Demographics
NPI:1346577798
Name:PK IMAGING CENTER
Entity Type:Organization
Organization Name:PK IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KIZZIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-683-9729
Mailing Address - Street 1:347 S 37TH ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4906
Mailing Address - Country:US
Mailing Address - Phone:918-683-9729
Mailing Address - Fax:918-683-1012
Practice Address - Street 1:347 S 37TH ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4906
Practice Address - Country:US
Practice Address - Phone:918-683-9729
Practice Address - Fax:918-683-1012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1508998808Medicare NSC