Healthcare Provider Details

I. General information

NPI: 1346216843
Provider Name (Legal Business Name): INTERLAKES MEDICAL CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 N WASHINGTON AVE
MADISON SD
57042-1634
US

IV. Provider business mailing address

903 N WASHINGTON AVE
MADISON SD
57042-1634
US

V. Phone/Fax

Practice location:
  • Phone: 605-256-6951
  • Fax: 605-256-6953
Mailing address:
  • Phone: 605-256-6951
  • Fax: 605-256-6953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0233
License Number StateSD

VIII. Authorized Official

Name: BARBARA SAMPLE
Title or Position: OFFICE MANAGER
Credential:
Phone: 605-256-6951