Healthcare Provider Details

I. General information

NPI: 1760465207
Provider Name (Legal Business Name): PLASTIC SURGICAL CENTER OF RAPID CITY, PROF. L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 5TH ST SUITE 100
RAPID CITY SD
57701-6014
US

IV. Provider business mailing address

3615 5TH ST SUITE 100
RAPID CITY SD
57701-6014
US

V. Phone/Fax

Practice location:
  • Phone: 605-343-6714
  • Fax: 605-343-2130
Mailing address:
  • Phone: 605-343-6714
  • Fax: 605-343-2130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number11152
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier81014
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerWELLMARK BCBS #

VIII. Authorized Official

Name: DR. ROBERT JAMES SCHUTZ
Title or Position: MD/MEDICAL DIRECTOR
Credential: M.D.
Phone: 605-343-6714