Basic Information
| Provider Information | |||||||||
| NPI: | 1881964484 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA QUEEN OF PEACE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA MEDICAL GROUP DE SMET | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 432 | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573010432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059956337 | ||||||||
| FaxNumber: | 6059955779 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 3RD ST SW | ||||||||
| Address2: | |||||||||
| City: | DE SMET | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572312224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058543834 | ||||||||
| FaxNumber: | 6058543878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2012 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EKEREN | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6056688322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.