Basic Information
Provider Information | |||||||||
NPI: | 1083763288 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | K ALAN KELTS MD STEVEN K HATA MD ROBERT C FINLEY MD ETAL PTRS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BLACK HILLS NEUROLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2929 5TH ST | ||||||||
Address2: | STE 240 | ||||||||
City: | RAPID CITY | ||||||||
State: | SD | ||||||||
PostalCode: | 577017363 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053413770 | ||||||||
FaxNumber: | 6053418692 | ||||||||
Practice Location | |||||||||
Address1: | 2929 5TH ST | ||||||||
Address2: | STE 240 | ||||||||
City: | RAPID CITY | ||||||||
State: | SD | ||||||||
PostalCode: | 577017363 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053413770 | ||||||||
FaxNumber: | 6053418692 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2007 | ||||||||
LastUpdateDate: | 07/06/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEWIS | ||||||||
AuthorizedOfficialFirstName: | JEANINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNTS | ||||||||
AuthorizedOfficialTelephone: | 6053413770 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 363AM0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 2084N0400X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 0000058 | 01 | SD | BC BS | OTHER | 102533300 | 05 | WY |   | MEDICAID |