Provider Demographics
NPI:1740491489
Name:PRAIRIE PEDIATRICS & ADOLESCENT CLINIC, P.C.
Entity type:Organization
Organization Name:PRAIRIE PEDIATRICS & ADOLESCENT CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:B
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-255-8901
Mailing Address - Street 1:1125 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105
Mailing Address - Country:US
Mailing Address - Phone:712-255-8901
Mailing Address - Fax:712-255-9161
Practice Address - Street 1:2534 GLENN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106
Practice Address - Country:US
Practice Address - Phone:712-274-7822
Practice Address - Fax:712-274-2556
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIE PEDIATRICS & ADOLESCENT CLINIC, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-24
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
71992Medicare PIN