1538644679 NPI number — BLACK HILLS ORTHOPEDIC & SPINE CENTER OF WYOMING PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538644679 NPI number — BLACK HILLS ORTHOPEDIC & SPINE CENTER OF WYOMING PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLACK HILLS ORTHOPEDIC & SPINE CENTER OF WYOMING 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:
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:
1538644679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6850
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAPID CITY
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57709-6850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-341-1414
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2201 S DOUGLAS HWY STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILLETTE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82718-5408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-446-9546
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MARRIS
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMIN ASST
Authorized Official Telephone Number:
605-737-9144

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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