Provider Demographics
NPI:1124184510
Name:RUSHMORE CLINIC, P.C.
Entity Type:Organization
Organization Name:RUSHMORE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KRAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-718-7450
Mailing Address - Street 1:101 E MINNESOTA ST
Mailing Address - Street 2:SUITE 260
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7756
Mailing Address - Country:US
Mailing Address - Phone:605-718-7450
Mailing Address - Fax:605-718-7465
Practice Address - Street 1:101 E MINNESOTA ST
Practice Address - Street 2:SUITE 260
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7756
Practice Address - Country:US
Practice Address - Phone:605-718-7450
Practice Address - Fax:605-718-7465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1584207R00000X
SD0348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3522835001OtherOWCP
SD40192OtherSECURE HORIZONS
WY2944830OtherWY WORKERS SAFETY
SD0040192OtherBLUE CROSS BLUE SHIELD
NE10025296700Medicaid
SD9202253OtherCAREWEST
SD9202253OtherDAKOTACARE
NE10025296700Medicaid
SD9202253OtherCAREWEST
SDCJ7398Medicare ID - Type UnspecifiedRAILROAD MEDICARE