Provider Demographics
NPI:1477733418
Name:PK XRAY, INC
Entity Type:Organization
Organization Name:PK XRAY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIPS
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 1:3379A GREEN ACRES RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-0236
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:2007-11-07
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARRT1299247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165224710Medicaid
AR19823Medicare PIN