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General NPI Number Information
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NPI Number | 1376821025
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Entity Type | Organization
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Legal Business Name | PRAIRIEVIEW GYN LLC
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Dates
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Enumeration Date | 07/29/2011
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Last Update Date | 07/29/2011
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Provider Practice Location Address
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Address Line | 3929 MORGAN TRL
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City | BOURBONNAIS
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State | IL
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Zip | 60914-4738
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Country | US
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Telephone | 815-935-1315
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Fax |
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Provider Business Mailing Address
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Address Line | 3929 MORGAN TRL
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City | BOURBONNAIS
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State | IL
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Zip | 60914-4738
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. DEGAULLE G HAILE
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Credential |
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Telephone | 815-935-1315
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | 036110330
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License Number State | IL
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