Basic Information
| Provider Information | |||||||||
| NPI: | 1841505807 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA ST MARYS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AVERA MEDICAL GROUP PIERRE - A DEPT OF AVERA ST MARYS HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MAC LN | ||||||||
| Address2: | |||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 575013391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052245901 | ||||||||
| FaxNumber: | 6059453177 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MAC LN | ||||||||
| Address2: | |||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 575013391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052245901 | ||||||||
| FaxNumber: | 6059453177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2010 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLAND | ||||||||
| AuthorizedOfficialFirstName: | MIKEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6052243144 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 10556 | SD | N | Hospitals | General Acute Care Hospital | 261QM1300X | SD | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.