Provider Demographics
NPI:1316986722
Name:MOBILE CARDIAC IMAGING, LLC
Entity type:Organization
Organization Name:MOBILE CARDIAC IMAGING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:JENETH
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-744-1001
Mailing Address - Street 1:7018 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3907
Mailing Address - Country:US
Mailing Address - Phone:918-744-1001
Mailing Address - Fax:918-744-9729
Practice Address - Street 1:7018 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3907
Practice Address - Country:US
Practice Address - Phone:918-744-1001
Practice Address - Fax:918-744-9729
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCI DIAGNOSTIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-05
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
OK3567261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200222370AMedicaid
OK200031560BMedicaid
OKOKB5944Medicare PIN
OK200222370AMedicaid