Healthcare Provider Details

I. General information

NPI: 1376896621
Provider Name (Legal Business Name): BLACK HILLS SURGICAL HOSPITAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1868 LOMBARDY DR
RAPID CITY SD
57703-4130
US

IV. Provider business mailing address

1868 LOMBARDY DR
RAPID CITY SD
57703-4130
US

V. Phone/Fax

Practice location:
  • Phone: 605-721-4900
  • Fax: 605-721-4964
Mailing address:
  • Phone: 605-721-4900
  • Fax: 605-721-4964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number10582
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code284300000X
TaxonomySpecial Hospital
License Number10582
License Number StateSD

VIII. Authorized Official

Name: MS. SUE SMITH
Title or Position: HIM MANAGER
Credential:
Phone: 605-721-4907