Healthcare Provider Details

I. General information

NPI: 1386790145
Provider Name (Legal Business Name): PRAIRIE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 SANTA MONICA BLVD SUITE 301
SANTA MONICA CA
90404
US

IV. Provider business mailing address

DEPARTMENT NO 2834
LOS ANGELES CA
90084
US

V. Phone/Fax

Practice location:
  • Phone: 310-082-9313
  • Fax: 310-828-9156
Mailing address:
  • Phone: 310-214-8677
  • Fax: 310-921-1718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number119553
License Number StateCA

VIII. Authorized Official

Name: DR. CHRISTOPHER C CHIDI
Title or Position: PRESIDENT
Credential: MD
Phone: 310-214-8677