Provider Demographics
NPI:1669578480
Name:CENTRAL STATES DIAGNOSTIC
Entity type:Organization
Organization Name:CENTRAL STATES DIAGNOSTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DICE
Authorized Official - Suffix:
Authorized Official - Credentials:ECHOCARDIOGRAPHER
Authorized Official - Phone:605-366-5397
Mailing Address - Street 1:1716 S MARION RD
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-3643
Mailing Address - Country:US
Mailing Address - Phone:605-366-5397
Mailing Address - Fax:605-256-3259
Practice Address - Street 1:25769 COTTONWOOD AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57107-6402
Practice Address - Country:US
Practice Address - Phone:605-366-5397
Practice Address - Fax:605-256-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0002272OtherBLUE SHIELD
SD7290070Medicaid
SD7290070Medicaid