MEDICARE: ADVANCED DERMATOLOGY OF THE BLACK HILLS, PC

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	207N00000X	Dermatology Physician
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1669125241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DERMATOLOGY OF THE BLACK HILLS, PC

Provider Business Mailing Address
First Line	:	PO BOX 1473
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57709-1473
Country	:	US
Telephone Number	:	605-721-0596
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 SAINT ANNE ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-4670
Country	:	US
Telephone Number	:	605-343-8000
Fax Number	:	605-343-8262

Authorized Official
Title or Position	:	OWNER/PHYSICIAN'S ASSISTANT
Name	:	MR. JONATHAN DEAN MEDECK
Credential	:	PA-C
Telephone Number	:	605-381-6082

Provider Enumeration Date	:	02/02/2022
Last Update Date	:	02/02/2022

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