Basic Information
| Provider Information | |||||||||
| NPI: | 1013981927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLISON | ||||||||
| FirstName: | MARTY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MAC LANE | ||||||||
| Address2: | AVERA MEDICAL GROUP PIERRE | ||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059455246 | ||||||||
| FaxNumber: | 6059455295 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MAC LANE | ||||||||
| Address2: | AVERA MEDICAL GROUP PIERRE | ||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059455246 | ||||||||
| FaxNumber: | 6059455295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 04/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4425 | SD | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | SD4425 | SD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6701223 | 05 | SD | MEDICAID | 6701220 | 05 | SD | MEDICAID |