Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 649 | SD |
NPI | 1124168398 |
---|---|
Provider Name | Jeff Monroe |
First Address | Pierre, SD 57501-4501 |
Second Address | Pierre, SD 57501-4501 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2007 |
Last Update Date | 10/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4999237 | WELLMARK BLUE CROSS (01) | SD |
7602602 | (05) | SD |
C649 | DAKOTACARE (01) | SD |
T66564 | (02) | SD |