Provider Demographics
NPI:1740590413
Name:INDEPENDENT MEDICINE PROF LLC
Entity Type:Organization
Organization Name:INDEPENDENT MEDICINE PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-371-6899
Mailing Address - Street 1:204 E LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ESTELLINE
Mailing Address - State:SD
Mailing Address - Zip Code:57234-6615
Mailing Address - Country:US
Mailing Address - Phone:605-873-2133
Mailing Address - Fax:605-873-2133
Practice Address - Street 1:204 E LAKE DR
Practice Address - Street 2:
Practice Address - City:ESTELLINE
Practice Address - State:SD
Practice Address - Zip Code:57234-6615
Practice Address - Country:US
Practice Address - Phone:605-873-2133
Practice Address - Fax:605-873-2133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6055207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS104706Medicare PIN