Provider Demographics
NPI:1518111376
Name:PRAIRIE SPINE AND PAIN INSTITUTE SC
Entity Type:Organization
Organization Name:PRAIRIE SPINE AND PAIN INSTITUTE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUBE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:309-691-7774
Mailing Address - Street 1:PO BOX 5173
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61601-5173
Mailing Address - Country:US
Mailing Address - Phone:309-691-6225
Mailing Address - Fax:
Practice Address - Street 1:7620 N UNIVERSITY ST
Practice Address - Street 2:STE. 104
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1297
Practice Address - Country:US
Practice Address - Phone:309-691-7774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6300610001Medicare NSC