Basic Information
| Provider Information | |||||||||
| NPI: | 1104330620 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAPID CITY REGIONAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | REGIONAL HEALTH MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860013 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554860013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052792149 | ||||||||
| FaxNumber: | 6052792139 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 7TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | WALL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577900010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052792149 | ||||||||
| FaxNumber: | 6052792139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2017 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | DAVIDSON | ||||||||
| AuthorizedOfficialFirstName: | RUTA | ||||||||
| AuthorizedOfficialMiddleName: | PAULETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | COO & PRESIDENT RAPID CITY MARKET | ||||||||
| AuthorizedOfficialTelephone: | 6057559138 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | N | Respite Care Facility | Respite Care | 253Z00000X | Y | Agencies | In Home Supportive Care |
ID Information
| ID | Type | State | Issuer | Description | 1457730673 | 05 | SD | MEDICAID |