Healthcare Provider Details

I. General information

NPI: 1659399756
Provider Name (Legal Business Name): SOUTH TULSA IMAGING, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7712 S YALE AVE SUITE 100
TULSA OK
74136-8332
US

IV. Provider business mailing address

7712 S YALE AVE SUITE 100
TULSA OK
74136-8332
US

V. Phone/Fax

Practice location:
  • Phone: 918-523-7226
  • Fax: 918-523-7227
Mailing address:
  • Phone: 918-523-7226
  • Fax: 918-523-7227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateOK

VIII. Authorized Official

Name: RANDY WAYNE WICKERSHAM
Title or Position: VP OF OPERATIONS
Credential:
Phone: 405-418-2200