Healthcare Provider Details

I. General information

NPI: 1538184114
Provider Name (Legal Business Name): PRAIRIE EMERGENCY GROUP, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VIRGINIA & FRANKLIN STREETS
NORMAL IL
61761
US

IV. Provider business mailing address

1 JODI LN
BLOOMINGTON IL
61701-2012
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-4321
  • Fax:
Mailing address:
  • Phone: 309-661-2247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier05721369
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBC/BS OF ILLINOIS

VIII. Authorized Official

Name: MR. MICHAEL J STRAZA
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 309-661-2247