Provider Demographics
NPI:1760453260
Name:RURAL MEDICAL CLINICS, PA
Entity Type:Organization
Organization Name:RURAL MEDICAL CLINICS, PA
Other - Org Name:BRIDGEWATER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:D
Authorized Official - Last Name:RIES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-925-4219
Mailing Address - Street 1:PO BOX 17
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:SD
Mailing Address - Zip Code:57319-0017
Mailing Address - Country:US
Mailing Address - Phone:605-729-2421
Mailing Address - Fax:
Practice Address - Street 1:208 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:SD
Practice Address - Zip Code:57319-0017
Practice Address - Country:US
Practice Address - Phone:605-729-2421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5300900Medicaid
S3188Medicare PIN
433891Medicare PIN
SD5300900Medicaid