Provider Demographics
NPI:1275750580
Name:SANFORD SCHOOL OF MEDICINE OF THE UNIVERSITY OF SOUTH DAKOTA CLINICAL
Entity Type:Organization
Organization Name:SANFORD SCHOOL OF MEDICINE OF THE UNIVERSITY OF SOUTH DAKOTA CLINICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPT. CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:605-336-3230
Mailing Address - Street 1:1400 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1505
Mailing Address - Country:US
Mailing Address - Phone:605-357-1380
Mailing Address - Fax:605-357-1548
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-394-5143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5580872Medicaid
SD0077925OtherBLUE CROSS AND BLUE SHIEL
SDS77925Medicare PIN