MEDICARE: STANDING ROCK SIOUX TRIBE

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	341600000X	Ambulance	041	ND

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	7210	OTHER	ND	BLUE CROSS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295824852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STANDING ROCK SIOUX TRIBE

Provider Business Mailing Address
First Line	:	PO BOX 974
Second Line	:
City	:	MANDAN
State	:	ND
Zip	:	58554-0974
Country	:	US
Telephone Number	:	701-250-6361
Fax Number	:

Provider Business Practice Location Address
First Line	:	9311 HIGHWAY 24
Second Line	:
City	:	FORT YATES
State	:	ND
Zip	:	58538-9621
Country	:	US
Telephone Number	:	701-854-3452
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DEAN PEGORS
Credential	:
Telephone Number	:	701-854-3452

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	04/29/2013

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Directions to “STANDING ROCK SIOUX TRIBE ” Practice Location

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