Basic Information
| Provider Information | |||||||||
| NPI: | 1326224627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUEEN CITY REGIONAL MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 N 10TH ST | ||||||||
| Address2: | |||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056428414 | ||||||||
| FaxNumber: | 6056428618 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 N. 10TH STREET | ||||||||
| Address2: | |||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056428414 | ||||||||
| FaxNumber: | 6056428618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2008 | ||||||||
| LastUpdateDate: | 01/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | GROUT | ||||||||
| AuthorizedOfficialFirstName: | LANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6056428414 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.