Healthcare Provider Details

I. General information

NPI: 1538332960
Provider Name (Legal Business Name): PRAIRIE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 S SEPULVEDA BLVD
LOS ANGELES CA
90045-3807
US

IV. Provider business mailing address

8540 S SEPULVEDA BLVD
LOS ANGELES CA
90045-3807
US

V. Phone/Fax

Practice location:
  • Phone: 310-214-8677
  • Fax:
Mailing address:
  • Phone: 310-214-8677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA53294
License Number StateCA

VIII. Authorized Official

Name: CHRISTOPHER CHIDI
Title or Position: OWNER PRESIDENT
Credential: MD
Phone: 310-214-8677