Basic Information
Provider Information | |||||||||
NPI: | 1124464128 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVERA ST. MARY'S | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVERA ST. MARY'S HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5045 | ||||||||
Address2: | CBO PALM PLACE PRV ENRLMT | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571175045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053226428 | ||||||||
FaxNumber: | 6052248339 | ||||||||
Practice Location | |||||||||
Address1: | 801 E SIOUX AVE | ||||||||
Address2: |   | ||||||||
City: | PIERRE | ||||||||
State: | SD | ||||||||
PostalCode: | 575013323 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6052243100 | ||||||||
FaxNumber: | 6052248339 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2013 | ||||||||
LastUpdateDate: | 07/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOLLAND | ||||||||
AuthorizedOfficialFirstName: | MIKEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6052243144 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | AVERA ST. MARY'S HOSPITAL CHILD ASSESSMENT CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
ID | Type | State | Issuer | Description | 5405080 | 05 | SD |   | MEDICAID |