Provider Demographics
NPI:1275068967
Name:PRAIRIE AVENUE PODIATRY GROUP
Entity Type:Organization
Organization Name:PRAIRIE AVENUE PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-671-5800
Mailing Address - Street 1:323 N PRAIRIE AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4505
Mailing Address - Country:US
Mailing Address - Phone:310-671-5800
Mailing Address - Fax:310-671-5810
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-671-5800
Practice Address - Fax:310-671-5810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2206213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB277242OtherMEDICARE NHIC