Basic Information
| Provider Information | |||||||||
| NPI: | 1750013793 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST RIVER PHYSICIANS ALLIANCE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057557649 | ||||||||
| FaxNumber: | 6057550707 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057557649 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2022 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | ARCHER | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER, CS EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 6057557118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.