Provider Demographics
NPI:1558464446
Name:DOUGLAS COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:DOUGLAS COUNTY MEMORIAL HOSPITAL
Other - Org Name:PRAIRIE HEALTH CLINIC - STICKNEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:NEUGEBAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-732-4508
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:301 MAIN STREET
Mailing Address - City:STICKNEY
Mailing Address - State:SD
Mailing Address - Zip Code:57375-0014
Mailing Address - Country:US
Mailing Address - Phone:605-732-4508
Mailing Address - Fax:
Practice Address - Street 1:301 MAIN STREET
Practice Address - Street 2:
Practice Address - City:STICKNEY
Practice Address - State:SD
Practice Address - Zip Code:57375-0014
Practice Address - Country:US
Practice Address - Phone:605-732-4508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOUGLAS COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5340420Medicaid
SD43D1039717OtherCLIA NUMBER
SD433425Medicare Oscar/Certification