Provider Demographics
NPI:1669544763
Name:OBSTETRICS AND GYNECOLOGY AND GYNECOLOGIC ONCOLOGY PC
Entity type:Organization
Organization Name:OBSTETRICS AND GYNECOLOGY AND GYNECOLOGIC ONCOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:Z
Authorized Official - Last Name:ABU-GHAZALEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-331-3898
Mailing Address - Street 1:1000 E 21ST ST
Mailing Address - Street 2:SUITE 3000
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1035
Mailing Address - Country:US
Mailing Address - Phone:605-331-3898
Mailing Address - Fax:605-331-3967
Practice Address - Street 1:1000 E 21ST ST
Practice Address - Street 2:SUITE 3000
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1035
Practice Address - Country:US
Practice Address - Phone:605-331-3898
Practice Address - Fax:605-331-3967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD2615207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6200290Medicaid
IA0925370Medicaid
IA0925370Medicaid
SD6200290Medicaid