Provider Demographics
NPI:1417912221
Name:PREMIER PET IMAGING OF WICHITA INC
Entity Type:Organization
Organization Name:PREMIER PET IMAGING OF WICHITA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-447-0046
Mailing Address - Street 1:PO BOX 343
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0343
Mailing Address - Country:US
Mailing Address - Phone:316-262-2015
Mailing Address - Fax:316-262-0983
Practice Address - Street 1:500 S MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3722
Practice Address - Country:US
Practice Address - Phone:316-263-4738
Practice Address - Fax:316-263-6697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS261Q00000X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS300124391 GRP#CH9838OtherRR MEDICARE
KS300124391 GRP#CH9838OtherRR MEDICARE