Healthcare Provider Details

I. General information

NPI: 1447275979
Provider Name (Legal Business Name): DR. MITCHEL LESTER RYDBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MITCHEL LESTER RYDBERG MD

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W 22ST VA MEDICAL CENTER
SIOUXF FALLS SD
57022
US

IV. Provider business mailing address

24562 473 AVE
DELL RAPIDS SD
57022
US

V. Phone/Fax

Practice location:
  • Phone: 605-336-3230
  • Fax: 605-333-5387
Mailing address:
  • Phone: 605-336-3230
  • Fax: 605-333-5387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2542
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: