Basic Information
Provider Information | |||||||||
NPI: | 1316913031 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAY | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 86370 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571186370 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053227510 | ||||||||
FaxNumber: | 6053226475 | ||||||||
Practice Location | |||||||||
Address1: | 116 W. 69TH ST., STE. 100 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 57108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053226960 | ||||||||
FaxNumber: | 6053226961 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2006 | ||||||||
LastUpdateDate: | 12/26/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 0668 | SD | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 0040222 | 01 | SD | BLUE CROSS | OTHER | 1663489 | 01 | SD | ARAZ/ AMERICA'S PPO | OTHER | 0668 | 01 | SD | DAKOTACARE | OTHER | 1529784 | 05 | IA |   | MEDICAID | 25104 | 01 | SD | SANFORD HEALTH PLAN | OTHER | 46022474343 | 05 | NE |   | MEDICAID | 0300193 | 01 | SD | MEDICA | OTHER | 397S2PA | 01 | MN | BLUE CROSS | OTHER | 5900382 | 05 | SD |   | MEDICAID | 407211028128 | 01 | SD | PREFERRED ONE | OTHER | 070016795 | 01 | SD | RR MEDICARE | OTHER | 16320 | 01 | SD | MIDLANDS CHOICE | OTHER | 57108B004 | 01 | SD | WPS TRICARE | OTHER | 040122003 | 01 | MN | PRIMEWEST | OTHER | 397S2PA | 01 | MN | CC SYSTEMS/ BLUE PLUS | OTHER | 470658700 | 05 | MN |   | MEDICAID | HP37149 | 01 | SD | HEALTHPARTNERS | OTHER |