Healthcare Provider Details

I. General information

NPI: 1407109705
Provider Name (Legal Business Name): HEART HOSPITAL OF SOUTH DAKOTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

4520 W 69TH ST
SIOUX FALLS SD
57108-8148
US

IV. Provider business mailing address

4500 W 69TH ST
SIOUX FALLS SD
57108-8148
US

V. Phone/Fax

Practice location:
  • Phone: 605-977-5000
  • Fax: 605-977-5377
Mailing address:
  • Phone: 605-977-7000
  • Fax: 605-977-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number41953
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number41953
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number41953
License Number StateSD
# 4
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number41953
License Number StateSD
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number41953
License Number StateSD

VIII. Authorized Official

Name: MR. JON C SODERHOLM
Title or Position: PRESIDENT
Credential:
Phone: 605-977-7005