Healthcare Provider Details

I. General information

NPI: 1265113260
Provider Name (Legal Business Name): TRAVIS J PTACEK MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 KANSAS CITY ST STE 203
RAPID CITY SD
57701-3693
US

IV. Provider business mailing address

529 KANSAS CITY ST STE 203
RAPID CITY SD
57701-3693
US

V. Phone/Fax

Practice location:
  • Phone: 605-223-0011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRAVIS PTACEK
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 605-223-0011