Healthcare Provider Details

I. General information

NPI: 1548392095
Provider Name (Legal Business Name): PAUL EDWARD STANSLAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2007
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 EAST HWY 18 / PINE RIDGE HOSPITAL BEHAVIORAL HEALTH DEPT./ INDIAN HEALTH SERVICE
PINE RIDGE SD
57770-1201
US

IV. Provider business mailing address

BEHAVIORAL HEALTH DEPT./ INDIAN HEALTH SERVICE PINE RIDGE HOSPITAL/ EAST HWY 18/ PO BOX 1201
PINE RIDGE SD
57770-1201
US

V. Phone/Fax

Practice location:
  • Phone: 605-867-3100
  • Fax: 605-867-3274
Mailing address:
  • Phone: 605-867-3100
  • Fax: 605-867-3274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number42587
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number256385-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: