Provider Demographics
NPI:1669125241
Name:ADVANCED DERMATOLOGY OF THE BLACK HILLS, PC
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY OF THE BLACK HILLS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN'S ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:MEDECK
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:605-381-6082
Mailing Address - Street 1:PO BOX 1473
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-1473
Mailing Address - Country:US
Mailing Address - Phone:605-721-0596
Mailing Address - Fax:
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:605-343-8000
Practice Address - Fax:605-343-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty