Provider Demographics
NPI:1669678777
Name:RUBIN-PECK, ELIZABETH DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:DIANE
Last Name:RUBIN-PECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:DIANE
Other - Last Name:PECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1521
Practice Address - Country:US
Practice Address - Phone:605-312-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD8400208000000X, 208M00000X
KS94-06746208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200675960AMedicaid
KSKA2129017OtherMEDICARE PTAN