Provider Demographics
NPI:1982714218
Name:PRAIRIE CARDIOVASCULAR CONSULTANTS, LTD.
Entity Type:Organization
Organization Name:PRAIRIE CARDIOVASCULAR CONSULTANTS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-788-0706
Mailing Address - Street 1:619 E MASON ST STE 4P57
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1034
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:217-788-0848
Practice Address - Street 1:619 E MASON ST STE 4P57
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1034
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-788-0848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
IL042003767174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCC1312OtherRAILROAD MEDICARE
ILCA3360OtherRAILROAD MEDICARE
ILCI5907OtherRAILROAD MEDICARE
ILCA6852OtherRAILROAD MEDICARE
ILCE0750OtherRAILROAD MEDICARE
ILCI5907OtherRAILROAD MEDICARE
IL517330Medicare ID - Type Unspecified
IL596500Medicare PIN