Provider Demographics
NPI:1407109705
Name:HEART HOSPITAL OF SOUTH DAKOTA LLC
Entity Type:Organization
Organization Name:HEART HOSPITAL OF SOUTH DAKOTA LLC
Other - Org Name:NORTH CENTRAL HEART A DIVISION OF AVERA HEART HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:C
Authorized Official - Last Name:SODERHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-977-7005
Mailing Address - Street 1:4500 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-8148
Mailing Address - Country:US
Mailing Address - Phone:605-977-7000
Mailing Address - Fax:605-977-7001
Practice Address - Street 1:4520 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8148
Practice Address - Country:US
Practice Address - Phone:605-977-5000
Practice Address - Fax:605-977-5377
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEART HOSPITAL OF SOUTH DAKOTA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD41953207RC0000X, 207RC0001X, 207RI0011X, 2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty