MEDICARE: BLACK HILLS FAMILY PRACTICE CLINIC PS

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	15628	OTHER	SLI
2	008N	OTHER	BLUE CROSS
3	75243	OTHER	UNIFORM
4	1009515	OTHER	COMMUNITY H
5	A002	OTHER	TRICARE
6	MA8267	OTHER	REGENCE
7	95958	OTHER	PACIFIC CARE
8	QMXPR0055448	OTHER	MOLINA
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	8009961	OTHER	AETNA

General Provider Information

NPI Number	:	1467542399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK HILLS FAMILY PRACTICE CLINIC PS

Provider Business Mailing Address
First Line	:	PO BOX 68
Second Line	:
City	:	MCCLEARY
State	:	WA
Zip	:	98557-0068
Country	:	US
Telephone Number	:	360-495-3475
Fax Number	:

Provider Business Practice Location Address
First Line	:	332 S BIRCH ST
Second Line	:
City	:	MCCLEARY
State	:	WA
Zip	:	98557-9522
Country	:	US
Telephone Number	:	360-495-3475
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EDWARD R MACKE
Credential	:	MD
Telephone Number	:	360-495-3475

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	10/13/2014

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Directions to “BLACK HILLS FAMILY PRACTICE CLINIC PS ” Practice Location

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