Provider Demographics
NPI:1417304924
Name:BLACK HILLS SURGICAL HOSPITAL, LLP
Entity Type:Organization
Organization Name:BLACK HILLS SURGICAL HOSPITAL, LLP
Other - Org Name:WEST RIVER EAR, NOSE, AND THROAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-721-4918
Mailing Address - Street 1:1868 LOMBARDY DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-4130
Mailing Address - Country:US
Mailing Address - Phone:605-721-4900
Mailing Address - Fax:605-721-4964
Practice Address - Street 1:1868 LOMBARDY DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57703-4130
Practice Address - Country:US
Practice Address - Phone:605-721-4900
Practice Address - Fax:605-721-4964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-16
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9104208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0108020Medicaid
SD5508020Medicaid
SD0108020Medicaid
SD430091Medicare Oscar/Certification