Provider Demographics
NPI:1861785354
Name:PRAIRIE SPINE & PAIN INSTITUTE OF SOUTHERN ILLINOIS, LLC
Entity type:Organization
Organization Name:PRAIRIE SPINE & PAIN INSTITUTE OF SOUTHERN ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUBE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:309-691-7774
Mailing Address - Street 1:PO BOX 5173
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61601-5173
Mailing Address - Country:US
Mailing Address - Phone:309-691-7774
Mailing Address - Fax:309-689-5768
Practice Address - Street 1:1306 N RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4570
Practice Address - Country:US
Practice Address - Phone:309-691-7774
Practice Address - Fax:309-689-5768
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIE SPINE & PAIN INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-17
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112907207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty