Provider Demographics
NPI:1205035581
Name:PRAIRIE SCHOONER EMERGENCY PHYSICIANS, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PRAIRIE SCHOONER EMERGENCY PHYSICIANS, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-401-2386
Mailing Address - Street 1:13737 NOEL RD
Mailing Address - Street 2:STE 1600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1331
Mailing Address - Country:US
Mailing Address - Phone:469-401-2386
Mailing Address - Fax:
Practice Address - Street 1:465 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3320
Practice Address - Country:US
Practice Address - Phone:559-784-8886
Practice Address - Fax:559-791-4802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37-1437692OtherBLUESHIELD
CAGI172AMedicare PIN
CA37-1437692OtherBLUESHIELD