Basic Information
| Provider Information | |||||||||
| NPI: | 1972538239 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIOUX VALLEY CLINIC | ||||||||
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| OtherOrganizationName: | SIOUX VALLEY LUNG/THORACIC TUMOR CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 E 54TH ST N | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571040681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053284539 | ||||||||
| FaxNumber: | 6053284531 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571050401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286035 | ||||||||
| FaxNumber: | 6053286010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOETSCH | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6053286940 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 364S00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | 10025056700 | 05 | NE | MEDICAID | 0537886 | 05 | IA | MEDICAID |