Provider Demographics
NPI:1033582556
Name:PRAIRIE MEDICAL LLC
Entity Type:Organization
Organization Name:PRAIRIE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-306-1804
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-0195
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-5741
Practice Address - Street 1:37868 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-8416
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:702-453-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55436-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty