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General NPI Number Information
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NPI Number | 1811088727
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Entity Type | Organization
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Legal Business Name | FAMILY MEDICINE CLINIC OF YANKTON PROFESSIONAL LLC
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Dates
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Enumeration Date | 09/27/2006
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Last Update Date | 04/05/2013
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Provider Practice Location Address
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Address Line | 1000 WEST 4TH STREET SUITE 15 FAMILY MEDICINE CLINIC OF YANKTON PROF LLC
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City | YANKTON
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State | SD
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Zip | 57078
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Country | US
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Telephone | 605-665-0555
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Fax | 605-665-4498
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Provider Business Mailing Address
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Address Line | 1000 WEST 4TH STREET SUITE 15 FAMILY MEDICINE CLINIC OF YANKTON PROF LLC
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City | YANKTON
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State | SD
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Zip | 57078
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Country | US
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Telephone | 605-665-0555
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Fax | 605-665-4498
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. KELLY R RAFFERTY
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Credential | MD
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Telephone | 605-665-0555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4270
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License Number State | SD
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