Provider Demographics
NPI:1871718551
Name:PRAIRIE HEALTH CARE, LTD
Entity type:Organization
Organization Name:PRAIRIE HEALTH CARE, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KLOSOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-895-9144
Mailing Address - Street 1:954 WEST STATE STREET
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60118
Mailing Address - Country:US
Mailing Address - Phone:815-895-9144
Mailing Address - Fax:815-899-4234
Practice Address - Street 1:954 WEST STATE STREET
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60118
Practice Address - Country:US
Practice Address - Phone:815-895-9144
Practice Address - Fax:815-899-4234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL729000Medicare PIN