Provider Demographics
NPI:1134471527
Name:LEWIS & CLARK SPECIALTY HOSPITAL LLC
Entity Type:Organization
Organization Name:LEWIS & CLARK SPECIALTY HOSPITAL LLC
Other - Org Name:LEWIS & CLARK FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:DOORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-665-5100
Mailing Address - Street 1:2525 FOX RUN PARKWAY
Mailing Address - Street 2:STE 200
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-5371
Mailing Address - Country:US
Mailing Address - Phone:605-260-2100
Mailing Address - Fax:605-665-5200
Practice Address - Street 1:2525 FOX RUN PARKWAY
Practice Address - Street 2:STE 200
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-5371
Practice Address - Country:US
Practice Address - Phone:605-260-2100
Practice Address - Fax:605-665-5200
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEWIS & CLARK SPECIALTY HOSPITAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-09
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD47834OtherDEPARTMENT OF HEALTH
SD5508070Medicaid
SD0108070Medicaid
SD430096OtherMEDICARE
SD5508070Medicaid