Basic Information
| Provider Information | |||||||||
| NPI: | 1518900125 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL ASSOCIATES CLINIC LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MAC LANE | ||||||||
| Address2: | P. O. BOX 758 | ||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052245901 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 MAC LANE | ||||||||
| Address2: | |||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052245901 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 11/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | KERZMAN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6052245901 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 0000022 | 01 | BLUE CROSS BLUE SHIELD | OTHER |