Provider Demographics
NPI:1427009034
Name:PRAIRIE STATES SURGICAL CENTER LLC
Entity type:Organization
Organization Name:PRAIRIE STATES SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-336-2638
Mailing Address - Street 1:2908 E 26TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-4034
Mailing Address - Country:US
Mailing Address - Phone:605-336-2638
Mailing Address - Fax:605-334-3500
Practice Address - Street 1:2908 E 26TH ST STE B
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-4034
Practice Address - Country:US
Practice Address - Phone:605-336-2638
Practice Address - Fax:605-334-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD47078261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0550558Medicaid
MN7Y49PROtherBLUE CROSS
MN826730800Medicaid
SD81017OtherBLUE CROSS
SD5490300Medicaid
SD=========OtherTAX ID
MN826730800Medicaid
SDS8040Medicare PIN