MEDICARE: DR. MARAH JO VAN DIEST MD

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	207Q00000X	Family Medicine Physician	14570	SD

General Provider Information

NPI Number	:	1952930273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARAH JO VAN DIEST MD

Provider Business Mailing Address
First Line	:	1200 S 7TH AVE
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-0900
Country	:	US
Telephone Number	:	605-504-5400
Fax Number	:	605-504-5150

Provider Business Practice Location Address
First Line	:	1600 S HIGHLINE AVE
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-1007
Country	:	US
Telephone Number	:	605-504-5600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2020
Last Update Date	:	08/18/2023

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