Basic Information
Provider Information | |||||||||
NPI: | 1497786412 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PINE RIDGE IHS HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1201 | ||||||||
Address2: |   | ||||||||
City: | PINE RIDGE | ||||||||
State: | SD | ||||||||
PostalCode: | 577701201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6058673032 | ||||||||
FaxNumber: | 6058673332 | ||||||||
Practice Location | |||||||||
Address1: | EAST HIGHWAY 18 | ||||||||
Address2: |   | ||||||||
City: | PINE RIDGE | ||||||||
State: | SD | ||||||||
PostalCode: | 577709998 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6058373314 | ||||||||
FaxNumber: | 6058673332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2006 | ||||||||
LastUpdateDate: | 09/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AKERS | ||||||||
AuthorizedOfficialFirstName: | RHONDA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6058673032 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PINE RIDGE INDIAN HEALTH SERVICE HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 341600000X |   |   | N |   | Transportation Services | Ambulance |   | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | HSZ153 | 01 |   | PTAN PART B | OTHER | AC0018 | 01 |   | ASC | OTHER |