Healthcare Provider Details

I. General information

NPI: 1104860683
Provider Name (Legal Business Name): SAMUEL W HUOT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 JACKSON BLVD
RAPID CITY SD
57702-3246
US

IV. Provider business mailing address

PO BOX 6020
RAPID CITY SD
57709-6020
US

V. Phone/Fax

Practice location:
  • Phone: 605-343-4050
  • Fax:
Mailing address:
  • Phone: 605-721-8354
  • Fax: 605-721-8458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1195
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: