Provider Demographics
NPI:1790955128
Name:ROSEBUD INDIAN HEALTH SERVICE
Entity Type:Organization
Organization Name:ROSEBUD INDIAN HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-747-2231
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:400 SOLDIER CREEK ROAD
Mailing Address - City:ROSEBUD
Mailing Address - State:SD
Mailing Address - Zip Code:57570-0400
Mailing Address - Country:US
Mailing Address - Phone:605-747-2231
Mailing Address - Fax:605-747-2216
Practice Address - Street 1:400 SOLDIER CREEK ROAD
Practice Address - Street 2:
Practice Address - City:ROSEBUD
Practice Address - State:SD
Practice Address - Zip Code:57570-0400
Practice Address - Country:US
Practice Address - Phone:605-747-2231
Practice Address - Fax:605-747-2216
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSEBUD INDIAN HEALTH SERVICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-29
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5540080Medicaid
SD0140080Medicaid
SD5549093Medicaid
SD5549520Medicaid
SD0140080Medicaid
SD5549093Medicaid
SD5549520Medicaid