Provider Demographics
NPI:1487266391
Name:PRAIRIE STATE ANESTHESIA ASSOCIATES, PLLC
Entity type:Organization
Organization Name:PRAIRIE STATE ANESTHESIA ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KREGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:205-999-4132
Mailing Address - Street 1:PO BOX 735448
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-5448
Mailing Address - Country:US
Mailing Address - Phone:888-337-3509
Mailing Address - Fax:941-328-3997
Practice Address - Street 1:5023 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-3453
Practice Address - Country:US
Practice Address - Phone:618-239-0678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2020-08-26
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