Organization
BLACK HILLS DERMATOLOGY PC
Active
Other names
Black Hills Dermatology and Laser Surgery Centre
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JASON W GORMAN (ADMINISTRATOR)
(605) 341-5565
Entity
Organization
Contact information
Practice address
7236 JORDAN DRIVE SUITE 101, RAPID CITY, SD 57702-8740
(605) 341-5565
(605) 341-5595
Mailing address
7236 JORDAN DRIVE SUITE 101, PO BOX 6540, RAPID CITY, SD 57709-6540
(605) 341-5565
(605) 341-5595
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
0370
SD
207ND0101X
MOHS-Micrographic Surgery Physician
0370
SD
207ND0900X
Dermatopathology Physician
0370
SD
207NP0225X
Pediatric Dermatology Physician
0370
SD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0040885
WELLMARK BCBS NUMBER
SD
Enumeration date
02/07/2006
Last updated
05/20/2008
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