Provider Demographics
NPI:1013010974
Name:WEST RIVER DERMATOLOGY, PC
Entity Type:Organization
Organization Name:WEST RIVER DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:S
Authorized Official - Last Name:KNUTSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-341-5910
Mailing Address - Street 1:717 MEADE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-5100
Mailing Address - Country:US
Mailing Address - Phone:605-341-5910
Mailing Address - Fax:605-341-9052
Practice Address - Street 1:717 MEADE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5100
Practice Address - Country:US
Practice Address - Phone:605-341-5910
Practice Address - Fax:605-341-9052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0266207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0003099OtherBLUE CROSS BLUE SHIELD
SD0003099OtherBLUE CROSS BLUE SHIELD
SDS3099Medicare PIN