Provider Demographics
NPI:1710995907
Name:FORT THOMPSON INDIAN HEALTH SERVICE
Entity Type:Organization
Organization Name:FORT THOMPSON INDIAN HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MADONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-245-1500
Mailing Address - Street 1:HWY 34 & 47
Mailing Address - Street 2:
Mailing Address - City:FORT THOMPSON
Mailing Address - State:SD
Mailing Address - Zip Code:57339-0200
Mailing Address - Country:US
Mailing Address - Phone:605-245-1500
Mailing Address - Fax:605-245-2384
Practice Address - Street 1:HWY 34 & 47
Practice Address - Street 2:
Practice Address - City:FORT THOMPSON
Practice Address - State:SD
Practice Address - Zip Code:57339-0200
Practice Address - Country:US
Practice Address - Phone:605-245-1500
Practice Address - Fax:605-245-2384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5549010Medicaid
SD=========OtherTAX ID NUMBER
SD5549010Medicaid