Provider Demographics
NPI:1760664502
Name:OBGYN SPECIALTY CLINIC PC
Entity Type:Organization
Organization Name:OBGYN SPECIALTY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMITRIEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-338-0836
Mailing Address - Street 1:625 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105
Mailing Address - Country:US
Mailing Address - Phone:605-338-0836
Mailing Address - Fax:605-338-7890
Practice Address - Street 1:625 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-338-0836
Practice Address - Fax:605-338-7890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3478207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDF09103Medicare UPIN
SDS40491Medicare PIN