Provider Demographics
NPI:1851458699
Name:PRAIRIE GLEN PRIMARY CARE, P.C.
Entity type:Organization
Organization Name:PRAIRIE GLEN PRIMARY CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ILAH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HELLER-BAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-257-5400
Mailing Address - Street 1:15505 127TH ST
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-4433
Mailing Address - Country:US
Mailing Address - Phone:630-257-5400
Mailing Address - Fax:630-257-1954
Practice Address - Street 1:15505 127TH ST
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-4433
Practice Address - Country:US
Practice Address - Phone:630-257-5400
Practice Address - Fax:630-257-1954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110756261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6599328OtherCIGNA
IL01634883OtherBLUE CROSS BLUE SHIELD O
IL036110756Medicaid
IL276OtherSILVER CROSS MANAGED CARE
IL5936374OtherAETNA
E53864Medicare UPIN
ILK15852Medicare ID - Type Unspecified