Provider Demographics
NPI:1013968718
Name:RUSHMORE AMBULATORY SURGERY CENTER
Entity Type:Organization
Organization Name:RUSHMORE AMBULATORY SURGERY CENTER
Other - Org Name:BLACK HILLS PEDIATRIC DENTISTRY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOBMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-718-9224
Mailing Address - Street 1:620 SHERIDAN LAKE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2490
Mailing Address - Country:US
Mailing Address - Phone:605-718-9224
Mailing Address - Fax:605-718-9225
Practice Address - Street 1:620 SHERIDAN LAKE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2406
Practice Address - Country:US
Practice Address - Phone:605-341-1314
Practice Address - Fax:605-341-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5490450Medicaid
SD81022OtherWELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA