Basic Information
Provider Information | |||||||||
NPI: | 1417378555 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVERA MARSHALL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVERA MEDICAL GROUP OPTOMETRY WORTHINGTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 S BRUCE ST | ||||||||
Address2: |   | ||||||||
City: | MARSHALL | ||||||||
State: | MN | ||||||||
PostalCode: | 562581934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5075329661 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 702 10TH ST | ||||||||
Address2: |   | ||||||||
City: | WORTHINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 561872767 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5073765535 | ||||||||
FaxNumber: | 5073764805 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/16/2013 | ||||||||
LastUpdateDate: | 12/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILLIAMS | ||||||||
AuthorizedOfficialFirstName: | SHARON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESEIDENT OF FINANCE/IS | ||||||||
AuthorizedOfficialTelephone: | 5075379150 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.