Provider Demographics
NPI:1659399756
Name:SOUTH TULSA IMAGING, L.L.C.
Entity Type:Organization
Organization Name:SOUTH TULSA IMAGING, L.L.C.
Other - Org Name:IMAGING SOLUTIONS OF TULSA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WICKERSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-418-2200
Mailing Address - Street 1:7712 S YALE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8332
Mailing Address - Country:US
Mailing Address - Phone:918-523-7226
Mailing Address - Fax:918-523-7227
Practice Address - Street 1:7712 S YALE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8332
Practice Address - Country:US
Practice Address - Phone:918-523-7226
Practice Address - Fax:918-523-7227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology