Basic Information
| Provider Information | |||||||||
| NPI: | 1053557967 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA QUEEN OF PEACE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA HOEK MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 N FOSTER ST | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573012966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059952000 | ||||||||
| FaxNumber: | 6059952441 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 SECOND ST SE | ||||||||
| Address2: | |||||||||
| City: | DE SMET | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572310463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058543834 | ||||||||
| FaxNumber: | 6058543878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2008 | ||||||||
| LastUpdateDate: | 03/01/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 6059952251 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0232SD | SD | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.