Provider Demographics
NPI:1336112358
Name:ALTSTIEL, TERRY L (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:ALTSTIEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN MEDICAL STAFF SERVICES
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 N 10TH ST
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783
Practice Address - Country:US
Practice Address - Phone:605-642-8414
Practice Address - Fax:605-642-8618
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1107208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7300480Medicaid
SDF52251Medicare UPIN