Healthcare Provider Details

I. General information

NPI: 1942236096
Provider Name (Legal Business Name): UNIVERSITY PHYSICIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W 22ND ST
SIOUX FALLS SD
57105-1501
US

IV. Provider business mailing address

PO BOX 89208
SIOUX FALLS SD
57109-9208
US

V. Phone/Fax

Practice location:
  • Phone: 605-782-2000
  • Fax: 605-782-2721
Mailing address:
  • Phone: 605-782-2000
  • Fax: 605-782-2721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TORY PAYNE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 605-782-2131