Basic Information
| Provider Information | |||||||||
| NPI: | 1295758266 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST BENEDICT HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AVERA ST. BENEDICT CERTIFIED RURAL HEALTH CLINIC, PARKSTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 401 W GLYNN DR | ||||||||
| Address2: | |||||||||
| City: | PARKSTON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573669605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059287961 | ||||||||
| FaxNumber: | 6059284417 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W GLYNN DR | ||||||||
| Address2: | |||||||||
| City: | PARKSTON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573669605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059287961 | ||||||||
| FaxNumber: | 6059284417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLASIUS | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6059283311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 0007353 | 01 | SD | WELLMARK PARKSTON CLINIC | OTHER | 5340070 | 05 | SD | MEDICAID |