1881824977 NPI number — AVERA ST. LUKE'S

Table of content: (NPI 1881824977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881824977 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:
AVERA MEDICAL GROUP NEUROLOGY ABERDEEN
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:
1881824977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57402-1460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-622-2605
Provider Business Mailing Address Fax Number:
605-622-2606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 S LLOYD ST
Provider Second Line Business Practice Location Address:
SUITE E202
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57401-4552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-622-2605
Provider Business Practice Location Address Fax Number:
605-622-2606
Provider Enumeration Date:
07/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
FORKEL
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
602-622-5125

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  10525 , 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)





Copyright © 2007-2024 www.npivalidator.com