Healthcare Provider Details

I. General information

NPI: 1457734733
Provider Name (Legal Business Name): PHYSICIAN & SURGEONS X-RAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2015
Last Update Date: 07/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N PORTER AVE STE 104
NORMAN OK
73071-6426
US

IV. Provider business mailing address

900 N PORTER AVE STE 104
NORMAN OK
73071-6426
US

V. Phone/Fax

Practice location:
  • Phone: 405-255-0488
  • Fax: 405-329-5149
Mailing address:
  • Phone: 405-255-0488
  • Fax: 405-329-5149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. TRACY GAYLENE HOLZBERLEIN
Title or Position: OWNER
Credential:
Phone: 405-255-0488