Basic Information
| Provider Information | |||||||||
| NPI: | 1982804969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PURUSHOTTAM | ||||||||
| FirstName: | BHASKAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | ATTN MSS | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2675165143 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4150 5TH ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577016022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057554300 | ||||||||
| FaxNumber: | 6057551027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MT189705 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0000X | 9505 | SD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.