Basic Information
| Provider Information | |||||||||
| NPI: | 1982714218 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRAIRIE CARDIOVASCULAR CONSULTANTS, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 E MASON ST STE 4P57 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627011034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177880706 | ||||||||
| FaxNumber: | 2177880848 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 E MASON ST STE 4P57 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627011034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177880706 | ||||||||
| FaxNumber: | 2177880848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | WATSON | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2177880706 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | CC1312 | 01 | IL | RAILROAD MEDICARE | OTHER | CA3360 | 01 | IL | RAILROAD MEDICARE | OTHER | CI5907 | 01 | IL | RAILROAD MEDICARE | OTHER | CA6852 | 01 | IL | RAILROAD MEDICARE | OTHER | CE0750 | 01 | IL | RAILROAD MEDICARE | OTHER |