Provider Demographics
NPI:1063499739
Name:PRAIRIE MEDICINE LTD
Entity Type:Organization
Organization Name:PRAIRIE MEDICINE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-326-6402
Mailing Address - Street 1:421 S BEAUMONT RD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-1905
Mailing Address - Country:US
Mailing Address - Phone:608-326-6402
Mailing Address - Fax:608-326-6404
Practice Address - Street 1:421 S BEAUMONT RD
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-1905
Practice Address - Country:US
Practice Address - Phone:608-326-6402
Practice Address - Fax:608-326-6404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0944967Medicaid
WI30071400Medicaid
IAI5227Medicare PIN
WI30071400Medicaid