Provider Demographics
NPI:1497727028
Name:BLACK HILLS DERMATOLOGY PC
Entity Type:Organization
Organization Name:BLACK HILLS DERMATOLOGY PC
Other - Org Name:BLACK HILLS DERMATOLOGY AND LASER SURGERY CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:W
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-341-5565
Mailing Address - Street 1:7236 JORDAN DRIVE SUITE 101
Mailing Address - Street 2:PO BOX 6540
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6540
Mailing Address - Country:US
Mailing Address - Phone:605-341-5565
Mailing Address - Fax:605-341-5595
Practice Address - Street 1:7236 JORDAN DRIVE SUITE 101
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8740
Practice Address - Country:US
Practice Address - Phone:605-341-5565
Practice Address - Fax:605-341-5595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0370207N00000X, 207ND0101X, 207ND0900X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0040885OtherWELLMARK BCBS NUMBER
SD=========OtherTRICARE ID NUMBER
SD=========OtherTRICARE ID NUMBER
WY9486Medicare ID - Type UnspecifiedWYOMING MEDICARE
SCDB4102Medicare ID - Type UnspecifiedRAILROAD MEDICARE NUMBER