Basic Information
| Provider Information | |||||||||
| NPI: | 1407109705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEART HOSPITAL OF SOUTH DAKOTA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH CENTRAL HEART A DIVISION OF AVERA HEART HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 W 69TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571088148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059777000 | ||||||||
| FaxNumber: | 6059777001 | ||||||||
| Practice Location | |||||||||
| Address1: | 4520 W 69TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571088148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059775000 | ||||||||
| FaxNumber: | 6059775377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2012 | ||||||||
| LastUpdateDate: | 10/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | SODERHOLM | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6059777005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEART HOSPITAL OF SOUTH DAKOTA LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | 41953 | SD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | 41953 | SD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 2086S0129X | 41953 | SD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | 41953 | SD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 207RC0000X | 41953 | SD | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.