Healthcare Provider Details

I. General information

NPI: 1740324177
Provider Name (Legal Business Name): PRAIRIE STATE SPORTS MEDICINE CENTER, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 FOXFIELD RD
ST CHARLES IL
60174-5799
US

IV. Provider business mailing address

1638 CHESTNUT HILL CT
SUGAR GROVE IL
60554-9336
US

V. Phone/Fax

Practice location:
  • Phone: 630-220-0625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. BRIAN BABKA
Title or Position: PRESIDENT
Credential: MD
Phone: 630-220-0625