Healthcare Provider Details

I. General information

NPI: 1982804969
Provider Name (Legal Business Name): BHASKAR PURUSHOTTAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 5TH ST
RAPID CITY SD
57701-6022
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTN MSS
RAPID CITY SD
57701-7350
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-4300
  • Fax: 605-755-1027
Mailing address:
  • Phone: 267-516-5143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT189705
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number9505
License Number StateSD

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: