Provider Demographics
NPI:1255332805
Name:PRAIRIELAND OUTPATIENT DIAGNOSTIC CENTER LLC
Entity Type:Organization
Organization Name:PRAIRIELAND OUTPATIENT DIAGNOSTIC CENTER LLC
Other - Org Name:DIGESTIVE DISEASE ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOHLFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-589-9024
Mailing Address - Street 1:2500 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:JAMISON
Mailing Address - State:PA
Mailing Address - Zip Code:18929-1098
Mailing Address - Country:US
Mailing Address - Phone:215-589-9024
Mailing Address - Fax:833-705-6301
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-268-3400
Practice Address - Fax:309-268-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210921Medicare PIN