MEDICARE: A I ADVANCE IMAGING OF TULSA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265561575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A I ADVANCE IMAGING OF TULSA LLC

Provider Business Mailing Address
First Line	:	6757 S YALE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-3302
Country	:	US
Telephone Number	:	918-523-0002
Fax Number	:	918-523-0030

Provider Business Practice Location Address
First Line	:	6757 S YALE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-3302
Country	:	US
Telephone Number	:	918-523-0002
Fax Number	:	918-523-0030

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	STEVEN T MCCORMACK
Credential	:	MD
Telephone Number	:	918-523-0002

Provider Enumeration Date	:	03/04/2007
Last Update Date	:	04/20/2016

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