Basic Information
| Provider Information | |||||||||
| NPI: | 1215349196 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRAIRIE CLINIC, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 HELEN ST | ||||||||
| Address2: | |||||||||
| City: | SAUK CITY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535831101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086433351 | ||||||||
| FaxNumber: | 6086433621 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 HELEN ST | ||||||||
| Address2: | |||||||||
| City: | SAUK CITY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535831101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086433351 | ||||||||
| FaxNumber: | 6086433621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 6086433351 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.