1093759318 NPI number — LYLE PRAIRIE MD

Table of content: LYLE PRAIRIE MD (NPI 1093759318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093759318 NPI number — LYLE PRAIRIE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRAIRIE
Provider First Name:
LYLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093759318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 ALLENS CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14618-3305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-410-6545
Provider Business Mailing Address Fax Number:
585-410-6560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 PORTLAND AVE
Provider Second Line Business Practice Location Address:
ROCHESTER GENERAL HOSPITAL
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14621-3001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-922-4159
Provider Business Practice Location Address Fax Number:
585-922-3731
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  206263 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 206263-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AN206263-6 . This is a "WORKERS' COMPENSATION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010203263 . This is a "EXCELLUS BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01753906 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103217AF . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0645 . This is a "EXCELLUS BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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