Provider Demographics
NPI:1720237548
Name:MOBRIDGE REGIONAL HOSPITAL
Entity Type:Organization
Organization Name:MOBRIDGE REGIONAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TISDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-845-3692
Mailing Address - Street 1:1401 10TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-1106
Mailing Address - Country:US
Mailing Address - Phone:605-845-3692
Mailing Address - Fax:605-845-8252
Practice Address - Street 1:1401 10TH AVE W
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-1106
Practice Address - Country:US
Practice Address - Phone:605-845-3692
Practice Address - Fax:605-845-8252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD48404251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5102080Medicaid