Basic Information
| Provider Information | |||||||||
| NPI: | 1174590806 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONUMENT HEALTH NETWORK, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MONUMENT HEALTH LEAD-DEADWOOD HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860013 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554860013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057176000 | ||||||||
| FaxNumber: | 6057176008 | ||||||||
| Practice Location | |||||||||
| Address1: | 61 CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | DEADWOOD | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577321303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057176000 | ||||||||
| FaxNumber: | 6057176008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHMIDT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CUSTER LD-DWD HOSPITAL | ||||||||
| AuthorizedOfficialTelephone: | 6057176020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 10535 | SD | N | Transportation Services | Ambulance | 3416L0300X | N | Transportation Services | Ambulance | Land Transport | 282NC0060X | 10535 | SD | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 5500040 | 05 | SD | MEDICAID | 0100040 | 05 | SD | MEDICAID |