Healthcare Provider Details

I. General information

NPI: 1275837379
Provider Name (Legal Business Name): SPECTRUM IMAGING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ROCKEFELLER DR
MUSKOGEE OK
74401-5075
US

IV. Provider business mailing address

PO BOX 21228 DEPT 130
TULSA OK
74121-1228
US

V. Phone/Fax

Practice location:
  • Phone: 918-684-2189
  • Fax:
Mailing address:
  • Phone: 405-486-7250
  • Fax: 706-653-1567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KERRY A TRETHEWAY
Title or Position: MANAGER
Credential:
Phone: 405-486-7250