Basic Information
| Provider Information | |||||||||
| NPI: | 1649223439 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA TYLER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AVERA MEDICAL GROUP TYLER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 240 WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561781201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072475921 | ||||||||
| FaxNumber: | 5072475184 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561780240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072475921 | ||||||||
| FaxNumber: | 5072475184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5075379150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 5T014TY | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 97635800 | 05 | MN | MEDICAID | C07385 | 01 | MN | PART B MC | OTHER |