Basic Information
| Provider Information | |||||||||
| NPI: | 1083671408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5126 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053351952 | ||||||||
| FaxNumber: | 6053739971 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 W 57TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571085054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054967667 | ||||||||
| FaxNumber: | 6054967699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 07/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 3923 | SD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1963462 | 05 | IA | MEDICAID | 14G07JE | 01 | MN | BCBS | OTHER | 6630172 | 05 | SD | MEDICAID | 4997594 | 01 | SD | BCBS | OTHER | 395781100 | 05 | MN | MEDICAID | 09466 | 01 | IA | BCBS | OTHER | 22305 | 01 | NE | BCBS | OTHER | 390005700 | 01 | SD | RAILROAD | OTHER |