Provider Demographics
NPI:1962466722
Name:PREMIER SPORTS IMAGING INC
Entity Type:Organization
Organization Name:PREMIER SPORTS IMAGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HISCOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-943-9200
Mailing Address - Street 1:PO BOX 27340
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85061-7340
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:7111 W BELL RD
Practice Address - Street 2:SUITE 104
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8551
Practice Address - Country:US
Practice Address - Phone:623-533-4465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ274712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0782750OtherBCBSAZ
AZ2Z3264OtherHEALTH NET OF AZ
AZ961905Medicaid
AZP00308017Medicare PIN
AZZ106582Medicare PIN