Basic Information
| Provider Information | |||||||||
| NPI: | 1184948267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK HILLS UROLOGY AT RAPID CITY MEDICAL CENTER LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2820 MOUNT RUSHMORE RD | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577015462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053423280 | ||||||||
| FaxNumber: | 6057218458 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 SAINT ANNE ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577014670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053484100 | ||||||||
| FaxNumber: | 6053480662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2010 | ||||||||
| LastUpdateDate: | 06/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | RIDDLE | ||||||||
| AuthorizedOfficialFirstName: | DARREL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6053423280 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | CR0392 | 01 | RAILROAD MEDICARE | OTHER |