Basic Information
| Provider Information | |||||||||
| NPI: | 1124056338 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA HOLY FAMILY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA HOLY FAMILY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 826 N 8TH ST | ||||||||
| Address2: | |||||||||
| City: | ESTHERVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513341528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123622631 | ||||||||
| FaxNumber: | 7123622636 | ||||||||
| Practice Location | |||||||||
| Address1: | 826 N 8TH ST | ||||||||
| Address2: | |||||||||
| City: | ESTHERVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513341528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123622631 | ||||||||
| FaxNumber: | 7123622636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HERZBERG | ||||||||
| AuthorizedOfficialFirstName: | DEB | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7123626160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0077057 | 05 | IA | MEDICAID | 32245 | 01 | IA | CARDIOLOGY SERV BL CR IA | OTHER | 677247100 | 05 | MN | MEDICAID | 06272 | 01 | IA | CRNA BL CR IA | OTHER | 0272773 | 05 | IA | MEDICAID | 27277 | 01 | IA | ER SERV BL CR IA | OTHER | 608921HO | 01 | BC MN CRNA | OTHER | 74065HO | 01 | MN | ER CARD BL MN | OTHER |