1417912221 NPI number — PREMIER PET IMAGING OF WICHITA INC

Table of content: (NPI 1417912221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417912221 NPI number — PREMIER PET IMAGING OF WICHITA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PET IMAGING OF WICHITA INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417912221
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 343
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67201-0343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-262-2015
Provider Business Mailing Address Fax Number:
316-262-0983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67202-3722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-263-4738
Provider Business Practice Location Address Fax Number:
316-263-6697
Provider Enumeration Date:
04/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAHONEY
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
561-447-0046

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  261Q00000X , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300124391 GRP#CH9838 . This is a "RR MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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