MEDICARE: PRAIRIE MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	058963	CA

General Provider Information

NPI Number	:	1043356272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAIRIE MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	DEPARTMENT NO 2834
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90084
Country	:	US
Telephone Number	:	310-214-8677
Fax Number	:	310-921-1718

Provider Business Practice Location Address
First Line	:	10100 CULVER BLVD
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90231
Country	:	US
Telephone Number	:	310-280-2700
Fax Number	:	310-837-7334

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHRISTOPHER C CHIDI
Credential	:	MD
Telephone Number	:	310-214-8677

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	08/22/2020

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