Provider Demographics
NPI:1972630275
Name:BLACK HILLS SURGICAL HOSPITAL, LLC
Entity type:Organization
Organization Name:BLACK HILLS SURGICAL HOSPITAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-721-4922
Mailing Address - Street 1:1868 LOMBARDY DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-4130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:216 ANAMARIA DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7366
Practice Address - Country:US
Practice Address - Phone:605-721-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10582207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0108020Medicaid
SD5508020Medicaid
SD0108020Medicaid
SD5508020Medicaid