Provider Demographics
NPI:1306920319
Name:PRAIRIE PEDIATRICS, PC
Entity type:Organization
Organization Name:PRAIRIE PEDIATRICS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
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:51105-1485
Mailing Address - Country:US
Mailing Address - Phone:712-255-8901
Mailing Address - Fax:712-255-9161
Practice Address - Street 1:1125 PIERCE ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1485
Practice Address - Country:US
Practice Address - Phone:712-255-8901
Practice Address - Fax:712-255-9161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA51104A001OtherTRICARE ENTITY ID
IA51104A001OtherTRICARE ENTITY ID