Provider Demographics
NPI:1902948896
Name:MOBRIDGE REGIONAL HOSPITAL
Entity Type:Organization
Organization Name:MOBRIDGE REGIONAL HOSPITAL
Other - Org Name:HOSPITAL AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:
Authorized Official - Last Name:TISDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-845-8164
Mailing Address - Street 1:1401 10TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601
Mailing Address - Country:US
Mailing Address - Phone:605-845-3692
Mailing Address - Fax:605-845-8252
Practice Address - Street 1:1401 10TH AVE W
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601
Practice Address - Country:US
Practice Address - Phone:605-845-3692
Practice Address - Fax:605-845-8252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD48404282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9010600Medicaid
SD431325Medicare Oscar/Certification