Basic Information
| Provider Information | |||||||||
| NPI: | 1487627097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNUDSON | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MENNING | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | ATTEN MEDICAL STAFF SERVICES | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577016000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1420 N 10TH STST | ||||||||
| Address2: | QUEEN CITY REGIONAL MEDICAL CLINIC | ||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056428414 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5715 | SD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5606960 | 05 | SD | MEDICAID |