Basic Information
| Provider Information | |||||||||
| NPI: | 1376930008 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRAIRIE EMERGENCY PHYSICIANS, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 REMIT DR # 1367 | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606750001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002107034 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 N EDWARD ST | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625264163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178768121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2015 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | DERIK | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8669165259 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.