Provider Demographics
NPI:1073538609
Name:MALSOM, ELOY P
Entity Type:Individual
Prefix:
First Name:ELOY
Middle Name:P
Last Name:MALSOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 6TH ST STE 201
Mailing Address - Street 2:PO BOX 8265
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-2722
Mailing Address - Country:US
Mailing Address - Phone:605-721-0337
Mailing Address - Fax:605-721-0043
Practice Address - Street 1:701 8TH AVE NW
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-1803
Practice Address - Country:US
Practice Address - Phone:605-225-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCR000259367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5751502Medicaid
SD6940Medicare ID - Type Unspecified