Basic Information
| Provider Information | |||||||||
| NPI: | 1619201829 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA QUEEN OF PEACE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AVERA MEDICAL GROUP SALEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 741 S HILL ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570588761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054253038 | ||||||||
| FaxNumber: | 6054253039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EKEREN | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6056688322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | NA | SD | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | S1639 | 01 | SD | MEDICARE PART B | OTHER | 00-00592 | 01 | SD | MEDICA | OTHER | 4991003 | 01 | SD | WELLMARK | OTHER | 5307012 | 05 | SD | MEDICAID | CR0890 | 01 | SD | MEDICARE RAILROAD | OTHER |