Healthcare Provider Details

I. General information

NPI: 1598705063
Provider Name (Legal Business Name): ROGER D SOUTHMAYD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAC LANE
PIERRE SD
57501-0758
US

IV. Provider business mailing address

100 MAC LANE
PIERRE SD
57501-0758
US

V. Phone/Fax

Practice location:
  • Phone: 605-224-5901
  • Fax: 605-945-5295
Mailing address:
  • Phone: 605-224-5901
  • Fax: 605-945-5295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCR000347
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: