1659438828 NPI number — AVERA ST. LUKE'S

Table of content: (NPI 1659438828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659438828 NPI number — AVERA ST. LUKE'S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA ST. LUKE'S
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARSHALL COUNTY MEDICAL CLINIC AVERA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659438828
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRITTON
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57430-0626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-448-5953
Provider Business Mailing Address Fax Number:
605-448-2304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRITTON
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57430-2274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-448-5953
Provider Business Practice Location Address Fax Number:
605-448-2304
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBSON
Authorized Official First Name:
RON
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
605-622-5125

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9172758 . This is a "DAKOTACARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 13974 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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