=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205803160
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONUMENT HEALTH NETWORK, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2006
-----------------------------------------------------
Last Update Date | 04/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1220 MONTGOMERY ST
-----------------------------------------------------
City | CUSTER
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57730-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-673-9400
-----------------------------------------------------
Fax | 605-673-9482
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 860013
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55486-0013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-673-9400
-----------------------------------------------------
Fax | 605-673-9482
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT CUSTER LEAD-DWD HOSPITAL
-----------------------------------------------------
Name | MARK C SCHMIDT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-717-6020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 275N00000X
-----------------------------------------------------
Taxonomy Name | Medicare Defined Swing Bed Hospital Unit
-----------------------------------------------------
License Number | 47660
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------