Healthcare Provider Details

I. General information

NPI: 1811375082
Provider Name (Legal Business Name): BENJAMIN N LACROSSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 W NORFOLK AVE STE R
NORFOLK NE
68701-4405
US

IV. Provider business mailing address

1104 W 8TH ST
YANKTON SD
57078-3306
US

V. Phone/Fax

Practice location:
  • Phone: 605-665-7841
  • Fax:
Mailing address:
  • Phone: 605-665-7841
  • Fax: 605-665-8337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number125.067240
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number125.067240
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number30932
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: