Basic Information
| Provider Information | |||||||||
| NPI: | 1770530446 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL ARTS CLINIC, PRO. L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 SAINT FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577014677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053422880 | ||||||||
| FaxNumber: | 6053884621 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 SAINT FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577014677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053422880 | ||||||||
| FaxNumber: | 6053884621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 12/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | QUASNEY | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6053422880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0008005 | 01 | SD | BCBS | OTHER | CH6722 | 01 | SD | RAILROAD MEDICARE | OTHER |