Healthcare Provider Details

I. General information

NPI: 1124184510
Provider Name (Legal Business Name): RUSHMORE CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MINNESOTA ST SUITE 260
RAPID CITY SD
57701-7756
US

IV. Provider business mailing address

101 E MINNESOTA ST SUITE 260
RAPID CITY SD
57701-7756
US

V. Phone/Fax

Practice location:
  • Phone: 605-718-7450
  • Fax: 605-718-7465
Mailing address:
  • Phone: 605-718-7450
  • Fax: 605-718-7465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1584
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0348
License Number StateSD

VIII. Authorized Official

Name: VICKY L KRAUSE
Title or Position: CLINIC MANAGER
Credential:
Phone: 605-718-7450