Basic Information
| Provider Information | |||||||||
| NPI: | 1447690631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FISH | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 S CLIFF AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053224425 | ||||||||
| FaxNumber: | 6053224499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 S CLIFF AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053228000 | ||||||||
| FaxNumber: | 5738849992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2013 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2013018187 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 11953 | SD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0210555 | 05 | OH | MEDICAID |