Healthcare Provider Details

I. General information

NPI: 1013968718
Provider Name (Legal Business Name): RUSHMORE AMBULATORY SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SHERIDAN LAKE RD SUITE 104
RAPID CITY SD
57702-2406
US

IV. Provider business mailing address

620 SHERIDAN LAKE RD STE 101
RAPID CITY SD
57702-2490
US

V. Phone/Fax

Practice location:
  • Phone: 605-341-1314
  • Fax: 605-341-5757
Mailing address:
  • Phone: 605-718-9224
  • Fax: 605-718-9225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier5490450
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier81022
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerWELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA

VIII. Authorized Official

Name: KELLI J JOBMAN
Title or Position: CEO
Credential: DDS
Phone: 605-718-9224