Provider Demographics
NPI:1760563688
Name:PRAIRIE PSYCHIATRY, SC
Entity Type:Organization
Organization Name:PRAIRIE PSYCHIATRY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:618-235-1582
Mailing Address - Street 1:301 W LINCOLN ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1901
Mailing Address - Country:US
Mailing Address - Phone:618-235-1582
Mailing Address - Fax:618-235-2473
Practice Address - Street 1:301 W LINCOLN ST
Practice Address - Street 2:SUITE 106
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1901
Practice Address - Country:US
Practice Address - Phone:618-235-1582
Practice Address - Fax:618-235-2473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL995890Medicare ID - Type Unspecified
F61869Medicare UPIN