MEDICARE: RUSHMORE AMBULATORY SURGERY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	81022	OTHER	SD	WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA

General Provider Information

NPI Number	:	1013968718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSHMORE AMBULATORY SURGERY CENTER

Provider Business Mailing Address
First Line	:	620 SHERIDAN LAKE RD STE 101
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2490
Country	:	US
Telephone Number	:	605-718-9224
Fax Number	:	605-718-9225

Provider Business Practice Location Address
First Line	:	620 SHERIDAN LAKE RD
Second Line	:	SUITE 104
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2406
Country	:	US
Telephone Number	:	605-341-1314
Fax Number	:	605-341-5757

Authorized Official
Title or Position	:	CEO
Name	:	KELLI J JOBMAN
Credential	:	DDS
Telephone Number	:	605-718-9224

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	08/09/2022

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Directions to “RUSHMORE AMBULATORY SURGERY CENTER ” Practice Location

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