Provider Demographics
NPI:1629109095
Name:GRAND CANYON MEDICAL IMAGING LLC
Entity Type:Organization
Organization Name:GRAND CANYON MEDICAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:BURGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-754-5800
Mailing Address - Street 1:PO BOX 73878
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-0130
Mailing Address - Country:US
Mailing Address - Phone:714-754-5804
Mailing Address - Fax:714-754-6800
Practice Address - Street 1:3269 STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-3619
Practice Address - Country:US
Practice Address - Phone:928-757-0620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ78352Medicare ID - Type Unspecified