Provider Demographics
NPI:1376821025
Name:PRAIRIEVIEW GYN LLC
Entity Type:Organization
Organization Name:PRAIRIEVIEW GYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEGAULLE
Authorized Official - Middle Name:G
Authorized Official - Last Name:HAILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-935-1315
Mailing Address - Street 1:3929 MORGAN TRL
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-4738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3929 MORGAN TRL
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-4738
Practice Address - Country:US
Practice Address - Phone:815-935-1315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110330207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty