MEDICARE: PROFESSIONAL MEDICAL CONSULTANTS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	4785	SD
2	207RI0200X	Infectious Disease Physician	4786	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0453	OTHER	SD	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1912024001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL MEDICAL CONSULTANTS PC

Provider Business Mailing Address
First Line	:	PO BOX 2652
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57709-2652
Country	:	US
Telephone Number	:	605-737-7777
Fax Number	:	605-737-7778

Provider Business Practice Location Address
First Line	:	550 N 5TH ST
Second Line	:	SUITE 110
City	:	RAPID CITY
State	:	SD
Zip	:	57701-1375
Country	:	US
Telephone Number	:	605-737-7777
Fax Number	:	605-737-7778

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MAUREEN ERIN STEPHENSON
Credential	:	D.O.
Telephone Number	:	605-737-7777

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	01/04/2008

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