MEDICARE: BLACK HILLS UROLOGY 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	208800000X	Urology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CG0319	OTHER	SD	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	0003536	OTHER	SD	BLUE CROSS BLUE SHIELD
3	9239296	OTHER	SD	DAKOTACARE

General Provider Information

NPI Number	:	1699885244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK HILLS UROLOGY PC

Provider Business Mailing Address
First Line	:	710 SAINT ANNE ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-4670
Country	:	US
Telephone Number	:	605-348-4100
Fax Number	:	605-348-0662

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	:	605-348-4100
Fax Number	:	605-348-0662

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	EVONNE CULVER
Credential	:
Telephone Number	:	605-348-4100

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	09/19/2007

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Directions to “BLACK HILLS UROLOGY PC ” Practice Location

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