Provider Demographics
NPI:1205889896
Name:OBENCHAIN, THEODORE G (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:G
Last Name:OBENCHAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3450
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-3450
Mailing Address - Country:US
Mailing Address - Phone:605-719-5650
Mailing Address - Fax:605-719-5655
Practice Address - Street 1:2805 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7306
Practice Address - Country:US
Practice Address - Phone:605-719-5650
Practice Address - Fax:605-719-5655
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD5439207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A86415Medicare UPIN