Provider Demographics
NPI:1972698306
Name:BREAST MRI OF OKLAHOMA LLC
Entity Type:Organization
Organization Name:BREAST MRI OF OKLAHOMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BREKKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-632-2323
Mailing Address - Street 1:PO BOX 108809
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-8809
Mailing Address - Country:US
Mailing Address - Phone:405-632-2323
Mailing Address - Fax:405-631-9315
Practice Address - Street 1:4300 MCAULEY BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8302
Practice Address - Country:US
Practice Address - Phone:405-749-7077
Practice Address - Fax:405-631-9315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK400522299Medicare PIN