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General NPI Number Information
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NPI Number | 1033582556
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Entity Type | Organization
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Legal Business Name | PRAIRIE MEDICAL LLC
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Dates
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Enumeration Date | 11/05/2015
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Last Update Date | 11/05/2015
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Provider Practice Location Address
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Address Line | 37868 US HIGHWAY 18
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City | PRAIRIE DU CHIEN
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State | WI
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Zip | 53821-8416
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Country | US
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Telephone | 702-453-3799
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Fax | 702-453-5741
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Provider Business Mailing Address
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Address Line | PO BOX 195
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City | PRAIRIE DU CHIEN
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State | WI
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Zip | 53821-0195
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Country | US
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Telephone | 702-453-3799
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Fax | 702-453-5741
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Authorized Official
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Title or Position | SOLE OWNER
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Name | MATTHEW OLSON
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Credential | MD
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Telephone | 608-306-1804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 55436-20
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License Number State | WI
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