Provider Demographics
NPI:1073727897
Name:MORTIMER, SAMUEL L (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:MORTIMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6850
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6850
Mailing Address - Country:US
Mailing Address - Phone:605-341-1414
Mailing Address - Fax:
Practice Address - Street 1:7220 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8754
Practice Address - Country:US
Practice Address - Phone:605-341-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7230207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1254560001OtherCIGNA MEDICARE
SD6402440Medicaid
SD1254560001OtherCIGNA MEDICARE