=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801281092
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN DWIGHT SHELMADINE D.O, PH.D, CSCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2015
-----------------------------------------------------
Last Update Date | 08/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1635 CAREGIVER CIR
-----------------------------------------------------
City | RAPID CITY
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57702-8529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-755-6100
-----------------------------------------------------
Fax | 605-755-6101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1635 CAREGIVER CIR
-----------------------------------------------------
City | RAPID CITY
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57702-8529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-755-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 11546
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------