Provider Demographics
NPI:1538644679
Name:BLACK HILLS ORTHOPEDIC & SPINE CENTER OF WYOMING PC
Entity Type:Organization
Organization Name:BLACK HILLS ORTHOPEDIC & SPINE CENTER OF WYOMING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASST
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-737-9144
Mailing Address - Street 1:PO BOX 6850
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6850
Mailing Address - Country:US
Mailing Address - Phone:605-341-1414
Mailing Address - Fax:
Practice Address - Street 1:2201 S DOUGLAS HWY STE 120
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5408
Practice Address - Country:US
Practice Address - Phone:800-446-9546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-25
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty