Provider Demographics
NPI:1174633614
Name:EIDEM, ERIC (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:EIDEM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 S HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8708
Mailing Address - Country:US
Mailing Address - Phone:605-341-1414
Mailing Address - Fax:605-341-7062
Practice Address - Street 1:7220 S HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8708
Practice Address - Country:US
Practice Address - Phone:605-341-1414
Practice Address - Fax:605-341-7062
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0486363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS105916Medicare PIN
SDS8489OtherSD MEDICARE
SD8489Medicare ID - Type Unspecified
970023973Medicare ID - Type UnspecifiedRAILROAD
SDS105916Medicare PIN
SD0008489OtherBLUE CROSS BLUE SHIELD
SD48824OtherSANFORD HEALTH
P48887Medicare UPIN
SD1002148Medicaid