Provider Demographics
NPI:1538184114
Name:PRAIRIE EMERGENCY GROUP, LTD.
Entity type:Organization
Organization Name:PRAIRIE EMERGENCY GROUP, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:STRAZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-661-2247
Mailing Address - Street 1:1 JODI LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-2012
Mailing Address - Country:US
Mailing Address - Phone:309-661-2247
Mailing Address - Fax:
Practice Address - Street 1:VIRGINIA & FRANKLIN STREETS
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-827-4321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05721369OtherBC/BS OF ILLINOIS
IL212058Medicare ID - Type Unspecified
ILDD6689Medicare PIN