=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346752656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRAIRIE FOOT & ANKLE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2017
-----------------------------------------------------
Last Update Date | 10/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7447 WEST TALCOTT AVE SUITE 406
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60163-3275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-227-6973
-----------------------------------------------------
Fax | 224-238-3296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7447 W TALCOTT AVE STE 406
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60631-3715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-227-6973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | DENISE MARY-DANIELLE LEE
-----------------------------------------------------
Credential | BSHA/MMHRM
-----------------------------------------------------
Telephone | 224-227-6973
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 016005367
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------