Basic Information
| Provider Information | |||||||||
| NPI: | 1174654081 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK HILLS REGIONAL EYE SURGERY CENTER, LLC | ||||||||
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| OtherOrganizationName: | BLACK HILLS REGIONAL SURGERY ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 3RD ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053412000 | ||||||||
| FaxNumber: | 6053410278 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 3RD ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053412000 | ||||||||
| FaxNumber: | 6053410278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 10/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | SUDRALA | ||||||||
| AuthorizedOfficialFirstName: | JODI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6053412000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.