Provider Demographics
NPI:1922726256
Name:BURGESS IMAGING, LLC
Entity Type:Organization
Organization Name:BURGESS IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHABON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-212-2558
Mailing Address - Street 1:508 E WILSON ST STE B
Mailing Address - Street 2:
Mailing Address - City:VALLIANT
Mailing Address - State:OK
Mailing Address - Zip Code:74764-9115
Mailing Address - Country:US
Mailing Address - Phone:833-851-7433
Mailing Address - Fax:
Practice Address - Street 1:508 E WILSON ST STE B
Practice Address - Street 2:
Practice Address - City:VALLIANT
Practice Address - State:OK
Practice Address - Zip Code:74764-9115
Practice Address - Country:US
Practice Address - Phone:580-933-9289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-22
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology