Provider Demographics
NPI:1275502577
Name:MOBRIDGE REGIONAL HOSPITAL
Entity Type:Organization
Organization Name:MOBRIDGE REGIONAL HOSPITAL
Other - Org Name:MOBRIDGE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:
Authorized Official - Last Name:TISDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-845-8164
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-0520
Mailing Address - Country:US
Mailing Address - Phone:605-845-3692
Mailing Address - Fax:605-845-8239
Practice Address - Street 1:1309 10TH AVE WEST
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-0520
Practice Address - Country:US
Practice Address - Phone:605-845-3692
Practice Address - Fax:605-845-8239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
SD438500261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS5203Medicare PIN
SD438500Medicare Oscar/Certification