Provider Demographics
NPI:1518313287
Name:PRAIRIE BLEEDING AND CLOTTING CENTER
Entity Type:Organization
Organization Name:PRAIRIE BLEEDING AND CLOTTING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OSVALDO
Authorized Official - Middle Name:H
Authorized Official - Last Name:WESLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-546-7100
Mailing Address - Street 1:105 S AMOS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1528
Mailing Address - Country:US
Mailing Address - Phone:217-546-7100
Mailing Address - Fax:217-546-7111
Practice Address - Street 1:105 S AMOS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1528
Practice Address - Country:US
Practice Address - Phone:217-546-7100
Practice Address - Fax:217-546-7111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.089289174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE91935Medicare UPIN