Provider Demographics
NPI:1700252228
Name:PRAIRIELAND OUTPATIENT DIAGNOSTIC CENTER, LLC
Entity Type:Organization
Organization Name:PRAIRIELAND OUTPATIENT DIAGNOSTIC CENTER, LLC
Other - Org Name:DIGESTIVE DISEASE ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOHLFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-589-9024
Mailing Address - Street 1:1302 FRANKLIN AVE
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3551
Mailing Address - Country:US
Mailing Address - Phone:309-268-3400
Mailing Address - Fax:309-268-3423
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-268-3400
Practice Address - Fax:309-268-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty