NPIMap

Individual provider Active NPI

Mikaela Theobald, PA-C

  • Physician Assistant
  • Rapid City, SD
National Provider Identifier
1124627898
Registry record updated Jun 29, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
Practice address
353 Fairmont Blvd
Rapid City, SD 57701-7375
Phone
(605) 755-1000
NPI assigned
Oct 22, 2020
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 29, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X Primary

Addresses

Primary practice location

353 Fairmont Blvd
Rapid City, SD 57701-7375

Mailing address

353 Fairmont Blvd
Rapid City, SD 57701-7375
Phone (605) 755-1000

Other practice location 1

353 Fairmont Blvd
Rapid City, SD 57701-7375
Phone (605) 755-1000

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SD
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20210405002455 SD Practitioner - Physician Assistant 7012324247 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2020
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

353 Fairmont Blvd
Rapid City, SD 57701-7375
Phone (605) 755-8109

677 Cathedral Dr
Suite 310
Rapid City, SD 57701-6018
Phone (605) 755-6720

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Avera McKennan CurrentSince Dec 22, 2020 Accepting new patients
Avera McKennan CurrentSince Dec 22, 2020 Accepting new patients
Monument Health Rapid City Hospital Inc CurrentSince Jan 12, 2022 Accepting new patients
Monument Health Rapid City Hospital, Inc. CurrentSince Jan 12, 2022 Accepting new patients

Locations

353 Fairmont Blvd
Rapid City, SD 57701
Phone (605) 719-1000

911 E 20th St
Ste 509
Sioux Falls, SD 57105
Phone (605) 322-5800

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 24

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 24

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1603324800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1687996800000",
    "number": "1124627898",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "353 FAIRMONT BLVD",
            "city": "RAPID CITY",
            "state": "SD",
            "postal_code": "577017375",
            "telephone_number": "605-755-1000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "353 FAIRMONT BLVD",
            "city": "RAPID CITY",
            "state": "SD",
            "postal_code": "577017375",
            "telephone_number": "605-755-1000"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "353 Fairmont Blvd",
            "address_purpose": "LOCATION",
            "city": "Rapid City",
            "state": "SD",
            "postal_code": "577017375",
            "country_code": "US",
            "telephone_number": "605-755-1000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "THEOBALD",
        "first_name": "MIKAELA",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-10-22",
        "last_updated": "2023-06-29",
        "certification_date": "2023-06-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Rapid City, SD

Sources for this page

Verify at the official NPI Registry.