1124184510 NPI number — RUSHMORE CLINIC, P.C.

Table of content: (NPI 1124184510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124184510 NPI number — RUSHMORE CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSHMORE CLINIC, P.C.
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:
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:
1124184510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E MINNESOTA ST
Provider Second Line Business Mailing Address:
SUITE 260
Provider Business Mailing Address City Name:
RAPID CITY
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57701-7756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-718-7450
Provider Business Mailing Address Fax Number:
605-718-7465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 E MINNESOTA ST
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
RAPID CITY
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57701-7756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-718-7450
Provider Business Practice Location Address Fax Number:
605-718-7465
Provider Enumeration Date:
12/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KRAUSE
Authorized Official First Name:
VICKY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CLINIC MANAGER
Authorized Official Telephone Number:
605-718-7450

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  1584 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 0348 , 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)

  • Identifier: 3522835001 . This is a "OWCP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 40192 . This is a "SECURE HORIZONS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 2944830 . This is a "WY WORKERS SAFETY" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 0040192 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 10025296700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9202253 . This is a "CAREWEST" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9202253 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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