Provider Demographics
NPI:1093760860
Name:ADULT AND ADOLESCENT INTERNAL MEDICINE
Entity Type:Organization
Organization Name:ADULT AND ADOLESCENT INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-335-1952
Mailing Address - Street 1:PO BOX 5126
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5126
Mailing Address - Country:US
Mailing Address - Phone:605-335-1952
Mailing Address - Fax:605-373-9971
Practice Address - Street 1:2200 N KIMBALL ST STE 300
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-1199
Practice Address - Country:US
Practice Address - Phone:605-995-0857
Practice Address - Fax:605-995-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0008099OtherBCBS
SDDF5256OtherRAILROAD MEDICARE
SDDF5256OtherRAILROAD MEDICARE