Provider Demographics
NPI:1639211527
Name:MOBRIDGE REGIONAL HOSPITAL
Entity Type:Organization
Organization Name:MOBRIDGE REGIONAL HOSPITAL
Other - Org Name:DME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:
Authorized Official - Last Name:TISDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-845-8164
Mailing Address - Street 1:1401 10TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-1106
Mailing Address - Country:US
Mailing Address - Phone:605-845-3692
Mailing Address - Fax:605-845-8252
Practice Address - Street 1:1401 10TH AVE W
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-1106
Practice Address - Country:US
Practice Address - Phone:605-845-3692
Practice Address - Fax:605-845-8252
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOBRIDGE REGIONAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-14
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD48404282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9163650Medicaid
SD9163650Medicaid