Provider Demographics
NPI:1093836827
Name:FOX PRAIRIE MEDICAL GROUP P C
Entity Type:Organization
Organization Name:FOX PRAIRIE MEDICAL GROUP P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STASIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KAHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-513-8734
Mailing Address - Street 1:2560 FOXFIELD RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5797
Mailing Address - Country:US
Mailing Address - Phone:630-513-8734
Mailing Address - Fax:630-513-1199
Practice Address - Street 1:2560 FOXFIELD RD
Practice Address - Street 2:SUITE 160
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5797
Practice Address - Country:US
Practice Address - Phone:630-513-8734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075143207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064522Medicaid
IL036075143Medicaid
IL036088803Medicaid
IL04532093OtherBLUE CROSS
ILC44262Medicare UPIN
ILL96814Medicare ID - Type UnspecifiedVIVIAN VANROEKEL, M.D.
IL036088803Medicaid
ILF80695Medicare ID - Type UnspecifiedSCOTT MCNAUGHTON, M.D.
ILL96813Medicare ID - Type UnspecifiedSTASIA KAHN, M.D.
IL04532093OtherBLUE CROSS
IL036064522Medicaid