Basic Information
| Provider Information | |||||||||
| NPI: | 1487266391 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRAIRIE STATE ANESTHESIA ASSOCIATES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 735448 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753735448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883373509 | ||||||||
| FaxNumber: | 9413283997 | ||||||||
| Practice Location | |||||||||
| Address1: | 5023 N ILLINOIS ST | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622083453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182390678 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2020 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | KREGER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2059994132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.