1689831091 NPI number — BLACK HILLS DERMATOLOGY PC

Table of content: (NPI 1689831091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689831091 NPI number — BLACK HILLS DERMATOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLACK HILLS DERMATOLOGY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SPEARFISH CLINIC
Provider Other Organization Name Type Code:
5
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:
1689831091
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6540
Provider Second Line Business Mailing Address:
7236 JORDAN DRIVE STE 101
Provider Business Mailing Address City Name:
RAPID CITY
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57709-6540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-341-5565
Provider Business Mailing Address Fax Number:
605-341-5595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132 E GRANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPEARFISH
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57783-2424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-722-9090
Provider Business Practice Location Address Fax Number:
605-722-9909
Provider Enumeration Date:
05/22/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GORMAN
Authorized Official First Name:
JASON
Authorized Official Middle Name:
W
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
605-341-5565

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  0370 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X , with the licence number: 0370 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0900X , with the licence number: 0370 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NP0225X , with the licence number: 0370 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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