Basic Information
| Provider Information | |||||||||
| NPI: | 1093760860 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADULT AND ADOLESCENT INTERNAL MEDICINE | ||||||||
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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: | 2200 N KIMBALL ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573011199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059950857 | ||||||||
| FaxNumber: | 6059950864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | BRANDT | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6053351952 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0008099 | 01 | SD | BCBS | OTHER | DF5256 | 01 | SD | RAILROAD MEDICARE | OTHER |