1932105046 NPI number — AVERA QUEEN OF PEACE

Table of content: (NPI 1932105046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932105046 NPI number — AVERA QUEEN OF PEACE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA QUEEN OF PEACE
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:
AVERA MEDICAL GROUP CORSICA
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:
1932105046
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 N FOSTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MITCHELL
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57301-2966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-995-2000
Provider Business Mailing Address Fax Number:
605-995-2441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
265 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORSICA
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-946-5411
Provider Business Practice Location Address Fax Number:
605-946-5206
Provider Enumeration Date:
06/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EKEREN
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
605-668-8322

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  N/A , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CR0890 . This is a "MEDICARE RR" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 5306742 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5306743 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000018 . This is a "WELLMARK" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: A-87545 . This is a "MULTIPLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 00-00435 . This is a "MEDICA" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".