Provider Demographics
NPI:1497871933
Name:STATE OF SOUTH DAKOTA
Entity Type:Organization
Organization Name:STATE OF SOUTH DAKOTA
Other - Org Name:USD SCOTTISH RITE SF CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE PROF, DEPARTMENT CHAIR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,CCC-A,FAAA,F-ASH
Authorized Official - Phone:605-677-5474
Mailing Address - Street 1:414 E CLARK ST
Mailing Address - Street 2:NOTEBOOM HALL
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-2307
Mailing Address - Country:US
Mailing Address - Phone:605-677-5474
Mailing Address - Fax:605-677-5767
Practice Address - Street 1:520 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-6902
Practice Address - Country:US
Practice Address - Phone:605-677-5474
Practice Address - Fax:605-677-5767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD231H00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5830560Medicaid