Provider Demographics
NPI:1033266945
Name:PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL
Entity Type:Organization
Organization Name:PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:POURIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-867-3021
Mailing Address - Street 1:P.O. BOX 1201
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-0275
Mailing Address - Country:US
Mailing Address - Phone:605-867-5131
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PORCUPINE
Practice Address - State:SD
Practice Address - Zip Code:57772
Practice Address - Country:US
Practice Address - Phone:605-867-5131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-04
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5540260Medicaid
SD5540260Medicaid
430081Medicare Oscar/Certification
PHS000Medicare UPIN