Healthcare Provider Details

I. General information

NPI: 1669125241
Provider Name (Legal Business Name): ADVANCED DERMATOLOGY OF THE BLACK HILLS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 SAINT ANNE ST
RAPID CITY SD
57701-4670
US

IV. Provider business mailing address

PO BOX 1473
RAPID CITY SD
57709-1473
US

V. Phone/Fax

Practice location:
  • Phone: 605-343-8000
  • Fax: 605-343-8262
Mailing address:
  • Phone: 605-721-0596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JONATHAN DEAN MEDECK
Title or Position: OWNER/PHYSICIAN'S ASSISTANT
Credential: PA-C
Phone: 605-381-6082