Provider Demographics
NPI:1184948267
Name:BLACK HILLS UROLOGY AT RAPID CITY MEDICAL CENTER LLP
Entity type:Organization
Organization Name:BLACK HILLS UROLOGY AT RAPID CITY MEDICAL CENTER LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DARREL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-342-3280
Mailing Address - Street 1:2820 MOUNT RUSHMORE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-5462
Mailing Address - Country:US
Mailing Address - Phone:605-342-3280
Mailing Address - Fax:605-721-8458
Practice Address - Street 1:710 SAINT ANNE ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4670
Practice Address - Country:US
Practice Address - Phone:605-348-4100
Practice Address - Fax:605-348-0662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CR0392OtherRAILROAD MEDICARE
SDS74Medicare PIN
CR0392OtherRAILROAD MEDICARE