Provider Demographics
NPI:1407902240
Name:PRAIRIE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PRAIRIE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHIDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-214-8677
Mailing Address - Street 1:DEPARTMENT NO 2834
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084
Mailing Address - Country:US
Mailing Address - Phone:310-214-8677
Mailing Address - Fax:310-921-1718
Practice Address - Street 1:323 N. PRAIRIE AVE
Practice Address - Street 2:SUITE 460
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301
Practice Address - Country:US
Practice Address - Phone:310-674-9010
Practice Address - Fax:310-677-5072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05529709174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078671Medicaid
CAW14046C W14046BMedicare PIN