Basic Information
| Provider Information | |||||||||
| NPI: | 1003363490 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MAC LN | ||||||||
| Address2: | |||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 575013391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052245901 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 MAC LN | ||||||||
| Address2: | |||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 575013391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052245901 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2016 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | ZELLMER | ||||||||
| AuthorizedOfficialFirstName: | JENNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | HR | ||||||||
| AuthorizedOfficialTelephone: | 6052245901 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AVERA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1052 | SD | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.