Healthcare Provider Details

I. General information

NPI: 1518313287
Provider Name (Legal Business Name): PRAIRIE BLEEDING AND CLOTTING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S AMOS AVE
SPRINGFIELD IL
62704-1528
US

IV. Provider business mailing address

105 S AMOS AVE
SPRINGFIELD IL
62704-1528
US

V. Phone/Fax

Practice location:
  • Phone: 217-546-7100
  • Fax: 217-546-7111
Mailing address:
  • Phone: 217-546-7100
  • Fax: 217-546-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036.089289
License Number StateIL

VIII. Authorized Official

Name: DR. OSVALDO H WESLY
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 217-414-1041