Provider Demographics
NPI:1902110836
Name:CREEKSIDE MEDICAL CLINIC, PROF. LLC
Entity Type:Organization
Organization Name:CREEKSIDE MEDICAL CLINIC, PROF. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BABBITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-341-1208
Mailing Address - Street 1:2620 JACKSON BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-1502
Mailing Address - Country:US
Mailing Address - Phone:605-341-1208
Mailing Address - Fax:
Practice Address - Street 1:2620 JACKSON BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-1502
Practice Address - Country:US
Practice Address - Phone:605-341-1208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4583207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5610718Medicaid
SD5610718Medicaid