Basic Information
| Provider Information | |||||||||
| NPI: | 1003230541 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGIONAL HEALTH PHYSICIANS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WALL REGIONAL MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057559142 | ||||||||
| FaxNumber: | 6057559140 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 7TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | WALL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052792149 | ||||||||
| FaxNumber: | 6052792139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2014 | ||||||||
| LastUpdateDate: | 02/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6057559042 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGIONAL HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | S300040 | 05 | SD | MEDICAID |