Provider Demographics
NPI:1659468718
Name:TALLGRASS OPEN MRI, L.L.C.
Entity Type:Organization
Organization Name:TALLGRASS OPEN MRI, L.L.C.
Other - Org Name:TALLGRASS DIAGNOSTIC IMAGING
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 1:7111 E 21ST ST N
Mailing Address - Street 2:SUITE B
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-1078
Mailing Address - Country:US
Mailing Address - Phone:316-925-4624
Mailing Address - Fax:316-925-4625
Practice Address - Street 1:7111 E 21ST ST N
Practice Address - Street 2:SUITE B
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1078
Practice Address - Country:US
Practice Address - Phone:316-925-4624
Practice Address - Fax:316-925-4625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)