Healthcare Provider Details

I. General information

NPI: 1033582556
Provider Name (Legal Business Name): PRAIRIE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37868 US HIGHWAY 18
PRAIRIE DU CHIEN WI
53821-8416
US

IV. Provider business mailing address

PO BOX 195
PRAIRIE DU CHIEN WI
53821-0195
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number55436-20
License Number StateWI

VIII. Authorized Official

Name: MATTHEW OLSON
Title or Position: SOLE OWNER
Credential: MD
Phone: 608-306-1804