Basic Information
| Provider Information | |||||||||
| NPI: | 1710995626 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA ST MARYS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AVERA ST MARYS HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 801 E SIOUX AVE | ||||||||
| Address2: | |||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052243100 | ||||||||
| FaxNumber: | 6052248339 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 E SIOUX AVE | ||||||||
| Address2: | |||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052243100 | ||||||||
| FaxNumber: | 6052248339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/07/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6052243127 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 437046 | SD | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 87046 | 01 | SD | BLUE CROSS PROVIDER # | OTHER | 0170030 | 05 | SD | MEDICAID |