Provider Demographics
NPI:1497878086
Name:PRAIRIE HEALTHCARE, LTD
Entity Type:Organization
Organization Name:PRAIRIE HEALTHCARE, LTD
Other - Org Name:SANDWICH FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-786-2722
Mailing Address - Street 1:1 E COUNTYLINE RD
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-2178
Mailing Address - Country:US
Mailing Address - Phone:815-786-2722
Mailing Address - Fax:
Practice Address - Street 1:1 E COUNTYLINE RD
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-2178
Practice Address - Country:US
Practice Address - Phone:815-786-2722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1921614OtherBLUECROSSBLUE SHIELD
IL1921614OtherBLUECROSSBLUE SHIELD