Healthcare Provider Details

I. General information

NPI: 1225115934
Provider Name (Legal Business Name): PRAIRIE ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S MICHIGAN AVE
CHICAGO IL
60616-2333
US

IV. Provider business mailing address

PO BOX 4602 DEPT 4041
OAK BROOK IL
60522-4602
US

V. Phone/Fax

Practice location:
  • Phone: 312-567-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MILORAD CUPIC
Title or Position: PRESIDENT
Credential:
Phone: 312-567-2000