Provider Demographics
NPI:1316900327
Name:RAPID CITY INDIAN HEALTH SERVICE HOSPITAL
Entity type:Organization
Organization Name:RAPID CITY INDIAN HEALTH SERVICE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-355-2423
Mailing Address - Street 1:3200 CANYON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8114
Mailing Address - Country:US
Mailing Address - Phone:605-355-2358
Mailing Address - Fax:605-355-2517
Practice Address - Street 1:3200 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8114
Practice Address - Country:US
Practice Address - Phone:605-355-2500
Practice Address - Fax:605-355-2517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0140070Medicaid
SD5549050Medicaid
SD0140070Medicaid
SDHSZ050Medicare PIN
SD5549050Medicaid