Provider Demographics
NPI:1053096354
Name:PRODIGY CARE SERVICES LLC
Entity type:Organization
Organization Name:PRODIGY CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:NORKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-800-7674
Mailing Address - Street 1:PO BOX 3161
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-3161
Mailing Address - Country:US
Mailing Address - Phone:713-322-6667
Mailing Address - Fax:
Practice Address - Street 1:5900 BALCONES DR STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4298
Practice Address - Country:US
Practice Address - Phone:713-322-6667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization