Provider Demographics
NPI:1144349747
Name:PRAIRIE PODIATRY L.L.C.
Entity type:Organization
Organization Name:PRAIRIE PODIATRY L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:SHOUDEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:217-698-6228
Mailing Address - Street 1:2070 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4174
Mailing Address - Country:US
Mailing Address - Phone:217-698-6228
Mailing Address - Fax:217-698-7241
Practice Address - Street 1:2070 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4174
Practice Address - Country:US
Practice Address - Phone:217-698-6228
Practice Address - Fax:217-698-7241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004443213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60101308OtherBLUE CROSS
IL369400Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL60101308OtherBLUE CROSS